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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service March 23, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately payable. 
 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2022, by an 
OON provider. 
 
You asked the Plan to pay for laboratory services. You say to please review the medical records and have the 
claim reprocessed for payment. 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 laboratory services provided on May 26, 2022, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 laboratory services provided on June 20, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown and core buildup services (D2740, 
D2950) 
 
You asked the Plan to pre-approve the porcelain crown and core buildup 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 there are no records to indicate necessity. 
 
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 a 
porcelain crown and core buildup services (D2740, D2950)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit with an orthopedic specialist 
and an x-ray. 
 
You asked the Plan to waive the copayment for a specialist office visit and an x-ray. You say that you do not 
feel that you should have to pay a copayment because you say the provider already knew the practice would be 
relocating before you could schedule surgery. 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 $45 
copayment for a specialist office visit and a $55 copayment for each Medicare-covered x-ray.  
 You have been asked to pay a $45 copayment for the office visit which falls within the physician/practitioner 
services, including doctors office visits benefit category. You have also been asked to pay a $10 copayment 
for the x-ray, which falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category.  
 
You have been asked to pay less than the required copayment of $55 for the x-ray, but you are only responsible 
for the lesser amount. This means that you have been asked to pay the correct amount based on your contract 
with the Plan (total cost share: $45 + $10 = $55). This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an office visit with an orthopedic specialist and an x-ray.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the treatment the enrollee received was 
medically necessary and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering and referring providers are both OON providers and there was no approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 30, 2021, billed 
with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194, 
and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code 
 
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 November 30, 2021, billed with codes 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81311, 81317, 81321, 81194, and 81309.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper 
spinal canal (72141). 
 
You asked the Plan to pre-approve an MRI of the upper spinal canal. You say that the enrollee is in a lot of 
pain, and cannot go to physical therapy. The Plan denied your request. The Plan says the enrollee does not meet 
all of the required criteria for an MRI of the upper spinal canal. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the upper spinal canal. Our 
reviewer says that an MRI of the upper spinal canal is not reasonable and necessary. Our physician reviewer 
found the MRI of the thoracic spine has been approved, and such approval was appropriate in this enrollee with 
T4-5 dermatome symptoms/neuralgia. Our reviewer also found that there is no history to suggest cervical spine 
neural compromise, and the requested MRI of the cervical spine is not yet medically necessary based upon the 
clinical information submitted and the referring clinician's willingness to cancel for now the order for the MRI 
of the cervical spine. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the upper spinal canal have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the upper spinal canal (72141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the integral lens service (S0590) purchased on June 15, 2022. 
 
You asked the Plan to pay for the integral lens service. You say that you went to have the lenses placed in the 
existing frames on this date of service. The Plan denied your request. The Plan says glasses or contact lenses 
are only allowed once per calendar year. The Plan also says that you already received glasses or contact lenses 
this year. 
 
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 up to 1 pair of routine contacts or eyeglasses per year. 
 
We looked at the file and the Plan's rules. The record shows that the Plan covered a pair of eyeglasses or 
contact lenses purchased on March 23, 2022, and your eyewear allowance has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the integral lens service have not been met. 
Therefore, we decided that the Plan does not have to pay for the integral lens service (S0590) purchased on 
June 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A9279 billed for date of service March 10, 
2022. 
 
You asked the Plan to pay for procedure code A9279. 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 A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code A9279 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A9279 billed for date of service March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on October 01, 
2021, to October 05, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you are on a fixed income and 
cannot afford the 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 $1,100 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,100 copayment for the inpatient care. 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. Per the EOC, there is a $275 copayment per day for days 1-5 of inpatient care. Your stay 
lasted 4 days from October 1, 2021, to October 5, 2021, for a total of $1,100. Therefore, we decided that the 
Plan does not have to waive the copayment for the inpatient care provided on October 01, 2021, to October 05, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the medical criteria for an IRF admission have been met. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient rehabilitation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on July 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical extraction. You say that you were advised that the provider's office 
you were treated by was in-network, otherwise you would not have gone there. You also say when you 
scheduled the appointment, the office did not say they were OON. The Plan denied your request. The Plan says 
the dental services were received from an OON 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 OON 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 OON provider. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210) provided on July 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to 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 an office visit provided on January 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high noble metal 
tooth #s 12, 15, 2, 4 (D6750), and pontic - porcelain fused to high noble metal tooth #s 13, 14, 3 (D6240). 
 
You asked the Plan to pre-approve a retainer crown - porcelain fused to high noble metal tooth #s 12, 15, 2, 4 
(D6750), and pontic - porcelain fused to high noble metal tooth #s 13, 14, 3 (D6240). The Plan denied your 
request. The Plan says to approve a bridge you must be missing only one upper front tooth or only two lower 
front teeth. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a retainer 
crown - porcelain fused to high noble metal tooth #s 12, 15, 2, 4 (D6750), and pontic - porcelain fused to high 
noble metal tooth #s 13, 14, 3 (D6240) 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 retainer crown - porcelain fused to 
high noble metal tooth #s 12, 15, 2, 4 (D6750), and pontic - porcelain fused to high noble metal tooth #s 13, 14, 
3 (D6240). Our reviewer says that fixed bridges to replace multiple posterior teeth is beyond the scope of the 
plan. Our physician reviewer found fixed bridges may be covered to replace a single maxillary anterior tooth or 
two adjacent mandibular anterior teeth and if no posterior teeth are missing. The documentation does not meet 
criteria for coverage for fixed bridges replacing tooth #'s 13, 14, and 3. 
 
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 retainer crown - porcelain fused to high noble metal tooth #s 12, 15, 2, 4 
(D6750), and pontic - porcelain fused to high noble metal  tooth #s 13, 14, 3 (D6240) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to high 
noble metal tooth #s 12, 15, 2, 4 (D6750), and pontic - porcelain fused to high noble metal tooth #s 13, 14, 3 
(D6240).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan for therapy guide provided April 
25, 2022. 
 
You asked the Plan to waive the copayment for a CT scan for therapy guide. You say that the scan was ordered 
by your provider as part of your treatment. You say that the Plan paid $0 towards the claim, and you would like 
a review. 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 $60 
copayment for each Medicare-covered radiation therapy service.  
 
 
  You have been asked to pay $48.91, which is less than the standard $60 copayment for a CT scan for therapy 
guide. This item/service falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for a CT scan for therapy guide 
provided April 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided on March 26, 2022, to April 24, 2022. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that you were 
not aware that the facility was out-of-network. 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 
$876.15 copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $876.15 copayment for the skilled nursing facility (SNF) care. This item/service 
falls within the skilled nursing facility (SNF) 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. Per the EOC, there is a $188 copayment per day for days 21-100 
of SNF care. Your stay lasted 29 days, for a total of $1,692 ($188 x 9 days = $1,692). However, the amount 
charged is $876.15 due to meeting your out-of-pocket maximum. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on March 26, 2022, to April 
24, 2022.