Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous surgical supply (A4649) provided on 
September 1, 2021. 
 
You asked the Plan to pay for miscellaneous surgical supply. You say that the requested item was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
Per the Physician Fee Schedule, CPT code A4649 has a status indicator of P. This means that the payment for 
A4649 is always bundled into the payment for another service or procedure. Based on this information, we 
decided that Medicare rules for coverage of miscellaneous surgical supply have not been met. Therefore, we 
decided that the Plan does not have to pay for miscellaneous surgical supply (A4649) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Speech therapy service and laryngoscopy on November 4, 2021.

You asked the Plan to waive the copayment for Speech therapy service and laryngoscopy. You say that surgery wasn't done during your visit. The Plan denied your request. The Plan says the cost share applied was correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment per day for Medicare covered speech language therapy services and a $290 copayment for each Medicare covered outpatient hospital facility visit for Speech therapy service and laryngoscopy. The total cost share amount is $320.

You have been asked to pay a $30 copayment per day for Medicare covered speech language therapy services and a $290 copayment for each Medicare covered outpatient hospital facility visit. Speech therapy service falls within the Outpatient rehabilitation services benefit category. Laryngoscopy 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 Speech therapy service and laryngoscopy on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services and procedures provided on 
July 19, 2021. 
 
You asked the Plan to pay for ophthalmology services and procedures. You say that the procedure was 
medically necessary for your vision. The Plan denied your request. The Plan says the physician stated to you 
that the procedure was not a covered benefit and would be a cosmetic procedure. BlephEx is not a covered 
benefit by the insurance Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.  Medicare rules say 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 there is insufficient 
information in the record to determine if Medicare rules for coverage of the ophthalmology services and 
procedures have been met. Therefore, we decided that the Plan does not have to pay for ophthalmology 
services and procedures provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office consultation (99241) provided on March 9, 2021. 
 
You asked the Plan to pay for code 99241. 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 CPT code 99241 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code 99241 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of code 99241 have not been met. Therefore, we decided that the Plan does not have to pay for the 
office consultation (99241) provided on March 9, 2021. Please note, the Plan reprocessed the rest of your claim 
for payment leaving you responsible for your 50% coinsurance for each service.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on September 29, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered when performed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
chiropractor submitted a claim for procedure codes 99204 (office visit), 97032 (electrical stimulation), and 
97012 (mechanical traction therapy). Therefore, we decided that the Plan does not have to pay for the 
chiropractic services rendered on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impacted tooth removal (D7230) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve an impacted tooth removal. You say that the removal of this tooth is 
medically necessary. The Plan denied your request. The Plan says D7230 is not a covered dental 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 an 
impacted tooth removal (D7230) to be provided by a participating provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular cancer genomics (CGx) (CPT code(s): 81408, 
81162, 81292, 81321, and 81407) provided on April 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
The Plan must follow Medicare rules. 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. Medicare denies 
coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be 
considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be 
submitted for the panel. Therefore, we decided that the Plan does not have to pay for molecular cancer 
genomics (CGx) (CPT code(s): 81408, 81162, 81292, 81321, and 81407) provided on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided on April 12, 2021. 
 
You asked the Plan to pay for codes 81286, 81238, 81410, and 81411. 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac risk 
assessment genetic screening testing provided on April 12, 2021.
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 January 6, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you thought this was covered 
every 6 months. The Plan denied your request. The Plan says the benefit limit of D0150 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 Plan's coverage rules apply in this case. The Plan covers one 
comprehensive oral evaluation every three years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was previously provided 
on June 1, 2021. Based on this information, we decided that the Plan's rules for coverage of a comprehensive 
oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by a participating provider on January 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim denied due to no transportation. 
 
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 November 2, 2021. 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 ambulance services provided to the enrollee on 
November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spectrometry testing (83789) provided on October 15, 2021. 
 
You asked the Plan to pay for spectrometry testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens used for drug testing shall not separately bill the validity testing. For example, if a laboratory 
performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine 
specimen is not adulterated, this testing is not separately billed. 
We find that CPT code 83789 is not supported in the medical record. Specifically, the records show that this 
testing was performed as validity testing for the specimen used for drug testing. Based on this information, we 
decided that Medicare rules for coverage of spectrometry testing have not been met. Therefore, we decided that 
the Plan does not have to pay for spectrometry testing (83789) provided on October 15, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the cost share for intravenous (IV) therapy, Part B drug, and a computed 
tomography (CT) scan provided by a network facility from June 30, 2021, to July 14, 2021. 
 
You asked the Plan to waive the cost share for the IV therapy, Part B drug, and the CT scan. You say that you 
feel that the provider is double charging. The Plan denied your request. The Plan says that you have been asked 
to pay the correct cost-sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit any documentation showing which codes were billed. 
This means we are unable to determine if the cost sharing amounts you are being asked to pay are correct. 
Therefore, we decided that the Plan has to waive the cost share for intravenous (IV) therapy, Part B drug, and a 
computed tomography (CT) scan provided by a network facility from June 30, 2021, to July 14, 2021. 
  
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 pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and intraoral images (D0210) provided by an out-of-network provider on October 5, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation, prophylaxis, and intraoral images. You say that 
all you had done was have your teeth cleaned. The Plan denied your request. The Plan says this claim has been 
processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. If you choose to see an out-of-
network dentist, you might be billed for any amount greater than what the plan pays. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive oral evaluation, prophylaxis, and intraoral images have been correctly applied. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis (D1110), and intraoral images (D0210) provided by an out-of-network provider on October 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 13, 2021 to 
March 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in addition to reporting a visit line using the G codes, 
HHAs must report an additional line item with the same revenue code and date of service. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the same date of 
service as the HIPPS code. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from February 13, 2021 to March 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on October 4, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You 
say that you only wanted your broken tooth addressed, but were told the x-rays would be covered by your 
insurance. You also say that you would like the $1,863.00 worth of charges for one tooth to be reconsidered. 
The Plan denied your request. The Plan says these services have exceeded the frequency limitations in your 
benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation 
(D0150) and complete series of intraoral x-rays (D0210), and are each limited to one procedure every three 
plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series 
of intraoral x-rays (D0210) on January 17, 2020 and your comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays 
(D0210) provided on October 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), two 
dimensional (2D) oral/facial photographic image (D0350), diagnostic casts (D0470), two guided tissue 
regenerations (D4267 x2), two surgical extractions (D7210 x2), two bone replacement grafts for ridge 
preservation (D7953 x2), and intravenous moderate (conscious) sedation/analgesia (D9239) provided from 
September 23, 2021, to October 15, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, 2D oral/facial photographic image, 
diagnostic casts, guided tissue regenerations, surgical extractions, bone replacement grafts, and intravenous 
moderate (conscious) sedation/analgesia. You say that a new claim has been filed and these procedures are 
covered. The Plan denied your request. The Plan says there are no records from your medical providers 
indicating that you have a medical condition requiring this oral surgery or bone grafting in order to treat 
conditions such as a fracture, cancer, or surgery of the jaw. The Plan also says that dental surgical procedures 
such as extractions, bone grafting, and bone stabilization are not procedures that treat a medical disease and are 
typically provided to prepare the jaw for dental implants. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140), two dimensional (2D) oral/facial photographic image (D0350), diagnostic casts (D0470), 
two guided tissue regenerations (D4267 x2), two surgical extractions (D7210 x2), two bone replacement grafts 
for ridge preservation (D7953 x2), and intravenous moderate (conscious) sedation/analgesia (D9239) provided 
from September 23, 2021, to October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement amount for an oxygen concentrator and a 
portable oxygen concentrator provided on March 30, 2021. 
 
You asked the Plan to increase the reimbursement amount for the oxygen concentrators. You say that everyone 
you spoke to at the insurance company gave you a different answer. You also say that you were told by a Plan 
representative that they thought the provider charged you too much. The Plan denied your request. The Plan 
says you have been reimbursed the correct 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 40% 
coinsurance for out-of-network durable medical equipment.  
 
You have been asked to pay $18, which is 40% of the allowed amount for a portable oxygen concentrator 
($45.01 allowed amount x 40% coinsurance = $18). You have also been asked to pay $54.75, which is 40% of 
the allowed amount for an oxygen concentrator ($136.87 allowed amount x 40% coinsurance = $54.75). You 
have been asked to pay a total of $72.75. ($18 coinsurance + $54.75 coinsurance = $72.75). The oxygen 
concentrators fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. You 
were reimbursed a total of $109.13 ($181.88 total allowed amount -$72.75 coinsurance = $109.13). This means 
that you have been reimbursed 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 increase the reimbursement amount for an oxygen concentrator and a portable oxygen 
concentrator provided on March 30, 2021.  
 
Please note that neither you nor the Plan are responsible for paying the balance bill. Please contact the 
provider about a refund for any amount you paid above the Medicare allowable amount for the oxygen 
concentrators. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please 
contact the Plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Speech treatment provided on May 25, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Speech treatment. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says prior authorization is required for an out-of-network 
visit. 
 
 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 Speech treatment provided on May 25, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive care management services for a single high-
risk disease (G2064) provided on November 15, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for comprehensive care management services for a single high-risk disease. You say 
that you do not have prior authorization. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the 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 comprehensive care management services for a 
single high-risk disease (G2064) provided on November 15, 2021, by an out-of-network (OON) provider.