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

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service June 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 3, 
2022. 
 You asked the Plan to pay for procedure code 93042. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 3, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network 
esophagogastroduodenoscopy (EGD) procedure provided on October 13, 2022. 
 
You asked the Plan to waive the copayment for an in-network esophagogastroduodenoscopy (EGD) procedure. 
You say that this was not a surgery so you should not have to pay this copayment. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment for outpatient surgery services rendered at an outpatient hospital. 
 
You have been asked to pay a $375 copayment for an in-network esophagogastroduodenoscopy (EGD) 
procedure. This item/service falls within the outpatient surgery services rendered at an outpatient hospital 
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 in-network 
esophagogastroduodenoscopy (EGD) procedure provided on October 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard injections to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve Gammagard injections to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
Gammagard injections to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery provided on August 25, 2022. 
 
You asked the Plan to pay for the cataract surgery. You say that a prior authorization request had been 
submitted. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the cataract surgery 
provided on August 25, 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 
provided on October 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you have a 
medical alert button. You also say that you did not call the ambulance and all they did was take your blood 
pressure when they arrived. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 October 14, 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 provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on October 10, 
2022. 
 
You asked the Plan to pay for principal care management services. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for principal care 
management services provided on October 10, 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 
provided on August 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you didn't 
call the ambulance. You also say that you declined the transport to the hospital because you felt fine after you 
were treated. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 August 12, 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 provided on August 12, 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 
provided on September 10, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are 
appealing the denial of the no transport. You also say that you did not want to go to the hospital and be exposed 
to COVID-19 or the flu. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 September 10, 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 provided on September 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 18, 2022. 
 
You asked the Plan to pay for lab services. You say that the services should be covered. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for lab services provided on August 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 03, 2022, to June 01, 
2022. 
 
You asked the Plan to pay for home health services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for home health services 
provided on May 03, 2022, to June 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Principal care management services provided on August 05, 
2022. 
 
You asked the Plan to pay for Principal care management services. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Principal care 
management services provided on August 05, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-ray exam provided on February 15, 2022. 
 
You asked the Plan to pay for an X-ray exam. The Plan denied your request. The Plan says Original Medicare 
is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an X-ray exam provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on September 
16, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that you need help paying for this. The Plan 
denied your request. The Plan says the rendered dental 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 pay for a bone 
replacement graft (D7953) provided on September 16, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy visit provided on 
August 23, 2022, to October 12, 2022. 
 
You asked the Plan to waive the copayment for each physical therapy visit. You say that you never receive 
services but are only asked to do positions and then walk away to someone else. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $30 copayment for each physical therapy visit. This item/service falls within the 
outpatient rehabilitation service 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. The total you owe is $210 ($30 per visit x 7 visits = $210). Therefore, we 
decided that the Plan does not have to waive the copayment for each physical therapy visit provided on August 
23, 2022, to October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal training sessions provided on March 22, 2022. 
 
You asked the Plan to pay for personal training sessions. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says you had not enrolled in the Plan vendor active program. 
The Plan also says that the program does not include fees associated with personal training sessions. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the enrollee enrolls in the active program and participate in the covered programs. Personal training 
sessions are excluded from this benefit.. 
 
The Plans rules for coverage of gym benefits have not been met because The Plan rules say the fitness 
program benefit gives you access to the Plan vendor. However, the record shows that you did not enroll in the 
Plan vendor active program. The record also shows that the program excludes personal training sessions from 
this benefit.. Therefore, we decided that the Plan does not have to pay for personal training sessions provided 
on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wound care visit provided on August 16, 2022. 
 
You asked the Plan to pay for a wound care visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a wound care visit 
provided on August 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from November 9, 2022, to November 11, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not understand 
the cost sharing applied to this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment per day, days 1 to 5, for in-network inpatient hospital care. 
 
You have been asked to pay a $650 copayment for the inpatient hospital stay ($325 x 2 days = $650). This 
item/service falls within the inpatient hospital 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 the inpatient hospital stay provided by an in-network provider from November 9, 2022, to 
November 11, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy sessions provided on August 4, 2022, to 
August 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy sessions. You say that this is medically necessary, please 
reconsider. The Plan denied your request. The Plan says There was no preauthorization by a primary care 
provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was not an 
emergency. Therefore, the decision is upheld. 
 
 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 physical therapy sessions provided on August 4, 
2022, to August 23, 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 personal protective equipment (D1999), osseous (D7950), 
unspecified oral surgery (D7999), evaluation for deep sedation (D9219), therapeutic parental drugs 
(D9610/D9612), and deep sedation (D9222/D9223), provided on June 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. 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 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 personal 
protective equipment (D1999), osseous (D7950), unspecified oral surgery (D7999), evaluation for deep 
sedation (D9219), therapeutic parental drugs (D9610/D9612), and deep sedation (D9222/D9223), provided on 
June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture base repair (D5512) provided 
on November 30, 2022. 
 
You asked the Plan to pay for a complete maxillary denture base repair. You say that you pay extra for dental 
benefits. The Plan denied your request. The Plan says the rendered dental 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 pay for a 
complete maxillary denture base repair (D5512) provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance.  
 
Benefits for Jardiance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.