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

 
We decided that the Plan does not have to pre-approve an injection to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve an injection. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an injection to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the specialist visit. You say that the in-network providers do not know how 
to treat the condition you have, and you would like to see an OON provider. The Plan denied your request. The 
Plan says there are specialist in-network that can provide the enrollee with a treatment plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist visit to be provided 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 December 16, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was previously seen, and the service 
was to establish care. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 December 16, 2021, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatologist services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve dermatologist services. You say that you would like to appeal the denial of 
the claim. The Plan denied your request. The Plan says the provider is out-of-network and it was determined 
these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dermatologist services to be provided 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 the ultrasound provided on November 30, 
2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that this should be a wellness visit 
charge. The Plan denied your request. The Plan says the copayment was applied 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 Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
  You have been asked to pay $90 for the ultrasound. An ultrasound falls within the Other outpatient diagnostic 
tests - Radiological diagnostic services, not including x-rays 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 ultrasound provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 2, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the office visit should be covered. 
The Plan denied your request. The Plan says the copayment was applied 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 $40 
copayment for each Medicare-covered primary care doctor visit when out-of-network.  
 
You have been asked to pay $40 for the office visit. An office visit 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. Therefore, we decided that the Plan does not have to waive the copayment 
for the office visit provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a hyaluronan or derivative, durolane, for 
intra-articular injection, an arthrocentesis, aspiration and/or injection provided on August 10, 2021. We also 
decided that the Plan does not have to waive the copayment for an office visit provided on August 17, 2021. 
 
You asked the Plan to waive the coinsurance for a hyaluronan or derivative, durolane, for intra-articular 
injection, an arthrocentesis, aspiration and/or injection. You also asked the Plan to waive the copayment for an 
office visit. You say that you recall an x-ray of the right now, pain medicine injection of what you were led to 
believe was a hyaluronic acid injection. You also say that when you came back several weeks later for the 
follow up, you asked the doctor if he was going to train the fluid buildup (lump) o your right knew and inject it with hyaluronic acid, and you were told no. The Plan denied your request. The Plan says you were charged the 
correct cost sharing amount. 
 
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 each Medicare-covered Part B Drug. Your contract with the Plan also says that you must pay a 
$40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office. 
 
You have been asked to pay $401.76 in coinsurance, which is 20% of the allowed amount for a hyaluronan or 
derivative, durolane, for intra-articular injection ($2,008.80 allowed amount x 20% coinsurance = $401.76). A 
hyaluronan or derivative, durolane, for intra-articular injection falls under the Medicare Part B Prescription 
Drugs benefit category.  You have also been asked to pay a $40 copayment for an arthrocentesis, aspiration 
and/or injection. You have also been asked to pay a $40 copayment for an office visit. An arthrocentesis, 
aspiration and/or injection, and an office visit fall within the physician/practitioner services, including doctors 
office visits benefit category. The record shows that these medical services were performed. 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 a hyaluronan or derivative, durolane, for intra-articular injection, an 
arthrocentesis, aspiration and/or injection provided on August 10, 2021. We also decided that the Plan does not 
have to waive the copayment for an office visit provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (J2701, 45385, 88305) provided October 
14, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says a corrected claim is needed. 
 
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 J2701, 45385, & 88305 is not supported in the medical record. Specifically, the claim 
was billed with an invalid Type of Bill. Based on this information, we decided that Medicare rules for coverage 
of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient services (J2701, 45385, 88305) provided October 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of an 
upper extremity provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the scan was necessary to determine 
the need for surgery and it should be covered. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $160 
copayment for radiological diagnostic services, such as CT scans.  
 
You have been asked to pay $134, which is less than the $160 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of an upper extremity provided 
on January 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206, 81275, 81276, and 81301) 
provided on May 25, 2021. 
 You asked the Plan to pay for the laboratory services (81206, 81275, 81276, and 81301). 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. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206, 81275, 81276, and 81301) provided on May 25, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crowns (D6750) for teeth # 3 and 6, and pontic (D6240) 
for tooth # 4. 
 
You asked the Plan to pre-approve a fixed bridge. You say that you need the bridge. You say that you cannot 
chew food. You say that you have a missing tooth and do not want to swallow your tooth without chewing. 
You also say that you have gum disease. The Plan denied your request. The Plan says that to approve a bridge 
you must be missing only one upper front tooth or only two lower front teeth. The Plan says that x-rays indicate 
you are missing other teeth. The Plan also says that the requested fixed bridge is not medically necessary. 
 
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 a fixed bridge 
when the services are medically necessary and reasonable. 
 
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 a fixed bridge. Our reviewer says that a 
fixed bridge for teeth # 3, 4 and 6 is medically necessary. Our physician reviewer found the documentation 
indicates that the enrollee is missing teeth # 4 and 5. The request is to replace these teeth with a single tooth 
since the space has closed to the extent that one tooth could be placed. The reviewer found that due to missing 
teeth in the lower left region, the enrollee has diminished masticatory function. The reviewer found that 
replacing tooth # 4 would restore adequate masticatory function on the right side. Therefore, the reviewer 
found that a fixed bridge is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a fixed bridge have been met. Therefore, we decided that the Plan has to pre-
approve retainer crowns (D6750) for teeth # 3 and 6, and pontic (D6240) for tooth # 4.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 2 and 3 and core buildups, 
including any pins when required (D2950) for tooth #'s 2 and 3. 
 
You asked the Plan to pre-approve crowns and core buildups. The Plan denied your request. The Plan says the 
x-rays and clinical notes submitted do not document or show evidence of recurrent decay or faulty margins. 
 
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 crowns and 
core buildups when the services are medically necessary and reasonable.  
 
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 crowns and core buildups. Our reviewer 
says that the documentation provided does not meet the criteria for coverage for core buildups (D2950) and 
replacement crowns (D2740) for tooth #'s 2 and 3. Our physician reviewer found that tooth #'s 2 and 3 have 
crowns in place which appear adequate. Our reviewer also found that there was no narrative indicating why the 
crowns needed to be replaced.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crowns and core buildups have not been met. Therefore, we decided that the 
Plan does not have to pre-approve crowns (D2740) for tooth #'s 2 and 3 and core buildups, including any pins 
when required (D2950) for tooth #'s 2 and 3.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81206 and 81292) provided on June 
9, 2021. 
 
You asked the Plan to pay for the laboratory services (81206 and 81292). 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. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81206 and 81292) provided on June 9, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Electrocardiogram (93010) provided on August 15, 2021. 
 
You asked the Plan to pay for code 93010. 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. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
is a column II code to column I code 29515. 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 the Electrocardiogram (93010) provided on August 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the 
upper left, upper right, lower left, and lower right quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. The Plan denied your request. The Plan says the 
x-rays show normal bone levels and no obvious bone loss evident. The Plan also says that there is no evidence 
of calculus (tartar) on the root surfaces. 
 
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 the scalings 
and planings when the services are medically necessary and reasonable.  
 
 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 the scalings and planings. Our reviewer 
says that the proposed treatment is not reasonable or medically necessary. Our physician reviewer found there 
are not four or more areas of root surface calculus or evidence of noticeable bone loss, the criteria for the 
scalings and root planings have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have not been met. Therefore, we decided that the 
Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the upper left, upper right, 
lower left, and lower right quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on December 23, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on 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 $10 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $10 copayment for the office visit. 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 office visit provided on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 25, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 January 25, 2022 by an 
out-of-network (OON) provider.