Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
November 01, 2021, to November 21, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 
being charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $178 copayment per day, days 21-100 for each SNF stay. A benefit period begins the day you go 
into a hospital or skilled nursing facility. The benefit period ends when you havent received any inpatient 
hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing 
facility after one benefit has ended, a new benefit period begins. There is no limit to the number of benefit 
periods you can have.  
 
 It was confirmed that you did not have 60 days between admission and days 1-20 $0 copayment were accessed 
on previous SNF claims. You received the first 20 days, at $0 copayment and then correctly assessed the $18 
copayment for the remainder of the stay. Due to the maximum out-of-pocket being met, the copayment was 
capped off at $2,800. You already paid $890 to SNF. $2,800 - $890 = $1,910. Therefore, results in the total 
cost sharing amount of $1,910.    
 
The enrollee has been asked to pay a $1,910 copayment for skilled nursing facility (SNF) care. Skilled nursing 
facility (SNF) care falls within the skilled nursing facility (SNF) care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for skilled nursing facility (SNF) care on November 01, 2021, to 
November 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 29, 2021 billed with 
codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 29, 2021 billed with codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81301, 81311, and 
81321.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited occlusal adjustment (D9951) provided on May 23, 
2022. 
 
You asked the Plan to pay for a limited occlusal adjustment. You say that the service was necessary, and you 
want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue 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 a limited 
occlusal adjustment (D9951) provided on May 23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal revascularization services 
coded C9606 provided on March 18, 2022. 
 
You asked the Plan to pay for the percutaneous transluminal revascularization services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We find that CPT code C9606 is not supported in the medical record. Specifically, this code is an inpatient 
procedure. However, this code was billed on the outpatient claim. Based on this information, we decided that 
Medicare rules for coverage of the percutaneous transluminal revascularization services have not been met. 
Therefore, we decided that the Plan does not have to pay for the percutaneous transluminal revascularization 
services coded C9606 provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for diagnostic imaging of the retina provided 
on June 2, 2021. 
 
You asked the Plan to lower the copayment for diagnostic imaging of the retina. You say that you didn't know 
you had this copayment, and never received a new EOC booklet. The Plan denied your request. The Plan says 
the copayment that was 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 $65 
copayment for a diagnostic procedure or test at a network doctors office.  
 
You are being charged $40.96 rather than the full copayment amount of $65 for a diagnostic imaging of the 
retina. Diagnostic imaging of the retina 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 lower the copayment for diagnostic imaging of the 
retina provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2022 billed with 
codes 0032U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81328, 81335, 
81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on their medical conditions. The Plan denied your request. The 
Plan says does not meet Medicare NCD/LCD criteria 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 11, 2022 billed with codes 0032U, 0032U, 0033U, 81225, 81227, 81230, 81231, 81232, 81291, 81306, 
81328, 81328, 81335, 81355.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on May 5, 
2022. 
 
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that you already paid a 
copayment at the time of the visit. The Plan denied your request. The Plan says you were charged this cost 
sharing 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 $20 
copayment for Medicare covered vision services.  
 
You have been asked to pay a $20 copayment for a diagnostic eye exam. A diagnostic eye exam falls within the 
Vision 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. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic eye exam 
provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp vitality tests (D0460) provided March 16, 2022. 
 
You asked the Plan to pay for the pulp vitality tests. You say that your dentist assured you that your root canal 
would be covered. The Plan denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp 
vitality tests (D0460) provided March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that this would be covered. 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 March 2, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided by a participating provider on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on December 10, 2021. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you did not know there would be a charge 
for this. The Plan denied your request. The Plan says the rendered dental work 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 a limited 
oral evaluation (D0140) provided by a participating provider on December 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from March 27, 2022, to April 21, 2022. 
 
You asked the Plan to waive the copayment for the SNF care. You say that the services should be fully 
covered. The Plan denied your request. The Plan says you were charged this cost sharing 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 $0 per 
day for days 1-20 and $150 per day for days 21-100 for each admission. 
 
Dates of Service Period Days Copayment 
March 27, 2022  April 15, 2022 1-20 $0/day 
April 16, 2022  April 21, 2022 21-25 $150/day 
Total:  $750 
 
 The file shows that you were in the nursing facility from March 27, 2022, to April 21, 2022. Therefore, you 
have been asked to pay $150 per day for days 21-25 of SNF care, for a total of $750. The SNF care falls within 
the Skilled Nursing Facility (SNF) 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. Therefore, we decided that the Plan does not have to waive the copayment 
for skilled nursing facility (SNF) care provided from March 27, 2022, to April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the extractions, of an erupted tooth or 
exposed root (D7140 x 17) provided on March 17, 2022 and April 14, 2022. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 extractions.  
 
You have been asked to pay $739.50 (Plans allowed amount of $1,479 x 50% coinsurance) for the dental 
extractions provided. 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 the extractions, of an erupted 
tooth or exposed root (D7140 x 17) provided on March 17, 2022 and April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for other drugs and/or medicaments dispensed in the office for 
home use (code D9630) and an unspecified preventive procedure (code D1999) provided on May 18, 2022. 
 
You asked the Plan to pay for other drugs and/or medicaments dispensed in the office for home use and an 
unspecified preventive procedure. You say that you believed your dental plan covered everything. The Plan 
denied your request. The Plan says the Plan will not cover the excluded services. 
 
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 other 
drugs and/or medicaments dispensed in the office for home use (code D9630) and an unspecified preventive 
procedure (code D1999) provided on May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CXbladder genetic testing services (0012M) provided on 
February 18, 2022. 
 
You asked the Plan to pay for the CXbladder genetic testing services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says this testing will not be 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a non-coverage policy in place for CPT 
codes 0012M and 0013M for CxBladder testing. Based on this information, we decided that Medicare rules for 
coverage of the CXbladder genetic testing services have not been met. Therefore, we decided that the Plan does 
not have to pay for the CXbladder genetic testing services (0012M) provided on February 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and the complete lower 
denture (D5120) provided on May 18, 2022. 
 
You asked the Plan to pay for the dental items. 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 items 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 items provided was exhausted on date of service January 22, 2020. Specifically, the 
Plan covers complete dentures once every five years. You previously received a complete upper and lower 
denture on January 22, 2020, which were paid for by the Plan. Therefore, you have exhausted the allowable 
benefit for these items. Therefore, we decided that the Plan does not have to pay for the complete upper denture 
(D5110) and the complete lower denture (D5120) provided on May 18, 2022.
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 8, 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 April 28, 2022. Specifically, the 
Plan provides coverage of one limited oral evaluation per year. You previously received this service on  
April 28, 2022, 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 limited oral evaluation-problem 
focused (D0140) provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator provided by an out-of-network 
provider on February 7, 2022. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that they told you they had to have the 
money up front, and that no insurance company would pay for this. The Plan denied your request. The Plan 
says there was no authorization on file for the out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided by an out-
of-network provider on February 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 27, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance came, helped you off the floor, and took your vitals. The Plan denied your request. The Plan says 
you were not transported to a facility for treatment. The Plan also says that the Health Plan is under no 
obligation to pay for services that do not include transport to a facility. 
 
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 April 27, 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 response and treatment with no 
transport (A0998) provided on April 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided May 13, 
2022. 
 
You asked the Plan to pay for the periodontal maintenance. You say that this cleaning did not feel any different 
than your regular cleanings. The Plan denied your request. The Plan says this service is not covered under your 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
November 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not satisfied with your previous dental 
services. 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 March 9, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on November 3, 2021.