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

 
We decided that the Plan does not have to pay for the office visit billed with code 99214 on August 26, 2022. 
 
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 procedure code 99214 is not supported. 
 
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, the CPT Code Manual definition of code 99214 is established patient office or other outpatient 
visit, 30-39 minutes. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, there is no documentation of 
a moderate level of medical decision making or total time required of the billed 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 office visit billed with code 99214 on August 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation provided on November 16, 2022. 
 
You asked the Plan to pay for the dental services. 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 do not fall 
within 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, 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 provided on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the natriuretic peptide (83800) provided February 3, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provided records support the necessity 
of the services in dispute. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD 
criteria. Natriuretic peptide, is not a Medicare benefit for the diagnoses listed on the claim and is done for 
screening purposes. 
 
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, the laboratory services, 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 natriuretic peptide (83800) provided February 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on September 16, 2022, to 
October 26, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you want to appeal the amount being 
charged. 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 $395 
copayment for outpatient hospital services. Covered services include but are not limited to services in an 
emergency department or outpatient clinic, such as observation services or outpatient surgery. There were two 
visits. 2 x $395 = $790. Therefore, results in the total cost sharing amount of $790.  
 
 
 
 
 You have been asked to pay a $395 copayment for each injection. This item/service falls within the outpatient 
hospital 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 copayment for injections on 
September 16, 2022, to October 26, 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 May 11, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical services team ran the tests without your consent so you should not be responsible for the 
charges. 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 May 11, 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 May 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 19, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) provided on June 1, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee did not meet criteria for coverage 
of the service provided. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture service have not been met. Specifically, the acupuncture service in this case was not rendered 
on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not have to pay 
for the acupuncture treatment (97810) provided on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2391) provided on September 22, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says your benefit for your annual maximum dental allowance has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your annual dental maximum allowance amount was exhausted on date of service September 22, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2391) provided on 
September 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network ultrasound provided on 
September 27, 2022. 
 
You asked the Plan to waive the copayment for an in-network ultrasound. You say that you were not given the 
correct information from the plan, and you are disappointed by their 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 $125 
copayment for Medicare-covered radiological diagnostic services.  
 
You have been asked to pay the allowed amount of $80.72 which is less than the $125 copayment for an in-
network ultrasound. This item/service falls within the Medicare-covered radiological diagnostic 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 copayment for an in-network ultrasound 
provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953), 
provided on September 29, 2022. 
 
You asked the Plan to pay for a bone replacement graft. You say that these services were medically necessary. 
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 for ridge preservation (D7953), provided on September 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and backup 
camera (K0108). 
 
You asked the Plan to pre-approve a power seat elevation system and backup camera. You say that the services 
are necessary. The Plan denied your request. The Plan says the requested items are not considered primarily 
medical in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a power seat elevation system and backup camera have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat elevation system (E2300) and backup camera (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and dental cleaning (D0120, 
D1110) provided on May 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation and dental cleaning (D0120, D1110) provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visit (99203) and the manual 
therapy services (97140 x 5) provided from August 10, 2022, through September 22, 2022. 
 
You asked the Plan to issue reimbursement 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. 
 
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 issue reimbursement for the office visit (99203) and the manual therapy services 
(97140 x 5) provided from August 10, 2022, through September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal adjustment (D9951) provided on June 27, 2022. 
 
You asked the Plan to pay for an occlusal adjustment. You say that if you knew it would be this expensive, you 
would not have had this done. 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 an 
occlusal adjustment (D9951) provided on June 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0483) provided on August 24, 2022. 
 
You asked the Plan to pay for drug testing. You say that this service was reported correctly and is supported as 
billed. The Plan denied your request. The Plan says that this service is not supported. 
 
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, the CPT Code Manual definition of 
code G0483 is drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the records show that drugs 
from at least 22 classes were tested in this case, including alkaloids (not otherwise specified), amphetamines, 
antidepressants (serotonergic class), antidepressants (not otherwise specified), benzodiazepines, buprenorphine, 
cocaine, fentanyls, gabapentin (non-blood), heroin metabolite, ketamine and norketamine, methadone, 
methylenedioxyamphetamines, methylphenidate, opiates, opioids and opiate analogs, oxycodone, pregabalin, 
sedative hypnotics (non-benzodiazepines), skeletal muscle relaxants, tapentadol and tramadol. In addition, 
although the Plan states that a physician order was provided for review, this document was not included in the 
case file sent to us. Based on this information, we decided that Medicare rules for coverage of drug testing have 
been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0483) provided on 
August 24, 2022.  
 
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 the trifocal lenses and the anti-reflective lens coating on 
October 19, 2022. 
 You asked the Plan to pay for the trifocal lenses and the anti-reflective lens coating. You say that your benefit 
cannot be exhausted because you only went to help with your eyeglasses once in 2022. The Plan denied your 
request. The Plan says the vision services benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $250. 
 
We looked at the file and the Plan's rules. Specifically, the $250 allowance was paid by the Plan on October 19, 
2022. Based on this information, we decided that the Plan's rules for coverage of the trifocal lenses and the 
anti-reflective lens coating have not been met. Therefore, we decided that the Plan does not have to pay for the 
trifocal lenses and the anti-reflective lens coating on October 19, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac rehabilitation services provided 
by an in-network provider from September 1, 2021, to November 4, 2021. 
 
You asked the Plan to waive the copayment for the cardiac rehabilitation services. You say that you were not 
told that there would be a cost share for these services. 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 each in-network Medicare-covered cardiac rehabilitation service and intensive cardiac 
rehabilitation service. 
 
 
 
 
 You have been asked to pay a $720 copayment for the cardiac rehabilitation services ($30 x 24 services = 
$720). These items/services fall within the cardiac rehabilitation 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 copayment for the cardiac rehabilitation services provided by an in-network 
provider from September 1, 2021, to November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014), progressive lenses (V2781), and anti-
reflective coating (V2750) provided on October 20, 2022. 
 
You asked the Plan to pay for the eye exam, progressive lenses, and anti-reflective coating. You say that you 
realize that you did not stay within the benefit period, but you were having real problems being able to see 
properly. You also say that since you are on a strict fixed income, you would like this claim to be reconsidered. 
The Plan denied your request. The Plan says these services exceed the frequency limits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one eye exam and one pair of standard lenses and frames every year. 
 
 
  We looked at the file and the Plan's rules. Specifically, the record shows that you received an eye exam and 
lenses on January 3, 2022, which were covered by the Plan, and your eye exam and lenses and frames benefits 
have been exhausted. Based on this information, we decided that the Plan's rules for coverage of the eye exam, 
progressive lenses, and anti-reflective coating have not been met. Therefore, we decided that the Plan does not 
have to pay for the eye exam (92014), progressive lenses (V2781), and anti-reflective coating (V2750) 
provided on October 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare Part B prescription drugs 
provided on November 28, 2022. 
 
You asked the Plan to waive the copayment for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs $1,328.99. You are being asked to pay $265.80 ($1,328.99 x 20% = 
$265.80). This item/service falls within the Medicare Part B prescription drugs 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 Medicare Part B prescription drugs provided on November 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided 
on October 15, 2022. 
 
You asked the Plan to pay for a CGM. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the date of service billed on this claim does not match the shipping date or the date 
or delivery. 
 
The Plan must follow Medicare rules. Medicare rules say that if a supplier utilizes a shipping service, the 
supplier may use the shipping date or the date of delivery as the date of service (DOS) on the claim. 
 
We looked at the file and Medicare rules. The record shows that the shipping date of this item was October 7, 
2022, and the delivery date was October 10, 2022. Therefore, the date of service billed on this claim, October 15, 2022, does not meet Medicare rules. Therefore, we decided that the Plan does not have to pay for a 
therapeutic continuous glucose monitor (CGM) provided on October 15, 2022.