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

 
We decided that the Plan does not have to pay for a psychotherapy office visit provided on February 28, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a psychotherapy office visit. You say that you are requesting the payment and are 
seeking a review. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychotherapy office visit provided on February 
28, 2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were unaware that 
you had a copayment for ambulance services. 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 $265 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $265 for these 
services. 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 ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic procedure (D0999) provided on May 13, 2022. 
 
You asked the Plan to pay for the diagnostic procedure. You say that you went for a new set of teeth. You also 
say that all they did was look at your mouth and took some x-rays. The Plan denied your request. The Plan says 
this service is not covered. The Plan also says that you were given a financial agreement to sign and were 
informed that any treatment not covered by the insurance would be your responsibility. 
 
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 
diagnostic procedure (D0999) provided on May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning. 
 
You asked the Plan to pre-approve fixed partial denture sectioning. You say that you are unable to afford 
bottom teeth, and this will assist with dealing with your bone deterioration. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fixed 
partial denture sectioning.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) Visit provided on 
April 25, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they 
were non-emergent and prior authorization was not obtained. 
 
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 the ER 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 emergency room (ER) Visit provided on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral/facial image (D0350) provided on May 7, 2022. 
 
You asked the Plan to pay for the 2D oral/facial image (D0350). You say that a billing person at the dental 
office called the Plan to check your coverage. You say that they were advised that the x-ray service would be 
covered but they did not check the tooth history. The Plan denied your request. The Plan says the 
comprehensive oral evaluation (D0150) and intraoral x-ray (D0210) have been paid. The Plan also says the 2D 
oral/facial image (D0350) 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 2D oral/facial image (D0350) is not 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral/facial 
image (D0350) on May 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supported retainer (D6069) and a pontic (D6240) for 
tooth #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30 
 
You asked the Plan to pre-approve the dental services. You say that the process of fixing your teeth has not 
been completed and you need the dental procedure done. The Plan denied your request. The Plan says due to 
the dental services requested by the enrollees provider the request for authorization is denied because the 
enrollee has reached their maximum coverage limit. 
 
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 prior to the request for authorization the yearly benefit amount used was $4,757.50. The requested dental 
services requested by the provider cost more the coverage amount left of $242.50 ($5,000 maximum amount - 
$4,757.50 used). Therefore, we decided that the Plan does not have to pre-approve a supported retainer 
(D6069) and a pontic (D6240) for tooth #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the Suboxone therapy (99214) 
provided from June 26, 2021, to November 13, 2021. 
 
You asked the Plan to waive the cost share amount for the opioid treatment services. You say that you received 
authorization to see this provider. The Plan denied your request. The Plan says there is a $30 copayment for 
opioid use disorder treatment services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for Opioid Treatment Program Services.  
 
You have been asked to pay a $30 copayment for the opioid treatment services. The opioid treatment services 
fall within the Opioid Treatment Program Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
cost share amount for the Suboxone therapy (99214) provided from June 26, 2021, to November 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve this dental service. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that services from an unassigned dentist are not 
covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider, who is not an assigned dentist. Though the 
Plan offers a dental benefit in excess of Medicare coverage, the requested service is not covered under this 
benefit when received from an out-of-network provider. The Plan contract says that for services to be covered, 
enrollees must receive dental care from the Plans select providers assigned dentist. Therefore, we decided that 
the Plan does not have to pre-approve a comprehensive oral evaluation (D0150).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, & 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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 
April 12, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, & 81294.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an evaluation (D0180) and a pre-diagnostic test (D0431 
provided on December 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the services were 
denied. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
an evaluation and pre-diagnostic test are not covered by the Plan. 
 
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 an 
evaluation (D0180) and a pre-diagnostic test (D0431 provided on December 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot x-ray (73630) and ankle x-ray (73610) provided on 
March 21, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that the enrollee cannot choose what radiologist reads their 
diagnostic tests. The Plan denied your request. The Plan says the services were provided out-of-service and 
were not approved in advance. 
  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 foot x-ray (73630) and ankle x-ray (73610) 
provided on March 21, 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 a limited oral evaluation (D0140) provided by a participating 
provider on May 9, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you fell and broke a tooth. You say that 
you needed this dental work. 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 May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057) and abutment supported 
crowns (D6059) for teeth # 10, 11, 12, 13, and 14. 
 
You asked the Plan to pre-approve the dental services. You say that you need to have the implants done 
because you already have the hooks in place. You also say that they cannot leave the work half done. The Plan 
denied your request. The Plan says custom abutments and abutment supported crowns are not listed as covered 
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 custom abutments and 
abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve custom abutments (D6057) and abutment supported crowns (D6059) for 
teeth # 10, 11, 12, 13, and 14.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87798, 87641 and 88305 
provided April 8, 2021.  
You asked the Plan to pay for the laboratory services. You say that the claim denied in error. Please review the 
attached supporting documents and reprocess the claim for payment. The Plan denied your request. The Plan 
says services received from ineligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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. Therefore, we decided that the Plan does not have to pay 
for the laboratory services coded as 87798, 87641 and 88305 provided April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation services (97032 x 8) provided from  
November 22, 2021, through December 20, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulation services (97032 x 8) provided from  
November 22, 2021, through December 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
13, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you did not receive any 
relief from this visit, therefore you feel you should not need to pay the copayment. The Plan denied your 
request. The Plan says the copayment 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 $120 
copayment for Emergency Care.  
 
You have been asked to pay a $120 copayment for an emergency room visit. An emergency room visit 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. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and an 
adjunctive pre-diagnostic test (D0431) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for a comprehensive periodontal evaluation (D0180) 
has already been exhausted. The Plan also says that an adjunctive pre-diagnostic test (D0431) is not covered by 
your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a comprehensive periodontal evaluation was exhausted on date of service May 5, 2022. 
An adjunctive pre-diagnostic test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) and an adjunctive pre-
diagnostic test (D0431) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic tooth-colored crown (D2750), and 
an upper and lower partial denture (D5213, D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you want the dental services covered. The 
Plan denied your request. The Plan says the records do not show an area of large decay requiring replacement 
of a significant amount of the tooth. The Plan says that the x-ray shows some decay, but the tooth can be 
restored with a regular filling. The Plan also says that the partial dentures are not covered under the Plans 
dental benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers crown 
restoration 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 porcelain/ceramic crown for tooth 
#11. Our reviewer says that the documentation provided does not show significant coronal breakdown of tooth 
#11 due to caries or fractures. Our physician reviewer found that the lack of adequate documentation means the 
criteria for coverage of a crown restoration of tooth #11 cannot be established.  
 
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 porcelain/ceramic crown have not been met. Furthermore, though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested upper and lower partial dentures are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain/ceramic tooth-colored crown (D2750), and an upper and lower partial denture (D5213, D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cystourethroscopy provided on May 3, 
2022. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you do not trust the office or 
the provider with the billing codes. 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 $275 
copayment for Medicare-covered ambulatory surgical center visit.  
 
You have been asked to pay a $275 copayment for a cystourethroscopy. A cystourethroscopy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 cystourethroscopy 
provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not a covered 
benefit under the enrollee's contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.