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

 
We decided that the Plan does not have to waive the coinsurance for eye injections provided on September 13, 
2022, to October 12, 2022. 
 
You asked the Plan to waive the coinsurance for eye injections. You say that due to not being told ahead of 
time there would be an out-of-pocket charge for these monthly injections, the Plan should pay the cost. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for eye injections. 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 coinsurance for eye 
injections provided on September 13, 2022, to October 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency taxi transportation (A0100), hotel stay 
(S9976), and sales tax (S9999) provided from May 9, 2022, to May 18, 2022. 
 
You asked the Plan to pay for the taxi transportation, hotel stay, and sales tax. You say that you were in 
mandatory quarantine due to COVID-19. You also say that prior to your trip, you were advised by the Plan that 
you did not need to take out additional medical coverage for your trip, because you were covered worldwide 
with the Plan you had. The Plan denied your request. The Plan says room and board in a hotel located outside 
the United States is not covered. The Plan also says taxi transportation is not covered outside the United States. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage. The rules also says that Medicare does not make separate payment for sales 
tax. 
 
We looked at the file and Medicare rules. Specifically, the Plan does not cover hotel stays (lodging), taxi 
transportation, and sales tax. The 2022 Evidence of Coverage clearly states that emergency or urgently needed 
care, and emergency ambulance transportation from the scene of an emergency are covered under your plan. 
Based on this information, we decided that Medicare rules for coverage of the taxi transportation, hotel stay, 
and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the non-
emergency taxi transportation (A0100), hotel stay (S9976), and sales tax (S9999) provided from May 9, 2022, 
to May 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on May 03, 
2022. 
 
You asked the Plan to pay for the magnetic resonance imaging (MRI). You say that a referral form was 
completed. 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). Please note that the referring provider is also not a Plan network provider. Therefore, 
we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on May 03, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service October 25, 
2022. 
 You asked the Plan to pay for procedure code 71045. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 71045 is bundled into 
payment for code 36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service October 25, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
16, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams on date of 
service September 16th, 2022. The Plan denied your request. The Plan says payment for code 70450 is bundled 
into payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service September 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 21, 2022. 
 
You asked the Plan to pay for home health services. 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 home health services 
provided on September 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 25, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with 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 $275 
copayment for outpatient surgery/surgery performed in an outpatient hospital setting.  
 
You have been asked to pay a $275 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery/surgery performed in an outpatient hospital setting 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 outpatient surgery provided on August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided on 
May 6, 2022. 
 
You asked the Plan to waive the copayment for the sacroiliac joint injection. You say that you cannot afford to 
pay the copayment for having my injection in an ambulatory surgical center. 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 $0 
copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening. $300 copayment for 
all other ambulatory surgical center (ACS) services. 
 
  You have been asked to pay $300 copayment for the sacroiliac joint injection provided at an ACS. This service 
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 the sacroiliac joint 
injection provided on May 6, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy services provided on November 
15, 2021. 
 
You asked the Plan to pay for medical nutrition therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says medical nutrition therapy is 
only covered for enrollees with diabetes and renal disease. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the 
Plan does not have to pay for the medical nutrition therapy services provided on November 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were told this would be in-network. The faciltiy 
needs to be changed. 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 an office visit provided 
on April 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positron emission tomography (PET) scan provided on June 
7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for PET scan. You say that the records attached support the services provided. The 
Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) scan 
provided on June 7, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), an extraction 
(D7140), and biological materials (D4265), provided by an out-of-network provider on October 6, 2022, 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should be paying 
more. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider. 
 
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 have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for D0140 and D7140. D4265 is not a covered benefit. 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 pay 
more for a limited oral evaluation (D0140), an extraction (D7140), and biological materials (D4265), provided 
by an out-of-network provider on October 6, 2022,
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network specialist office visit 
provided on September 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network specialist office visit. You say that there should 
not be a copay on this, it is considered routine foot care. 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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for an in-network specialist office visit. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 specialist office visit provided on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan and 
endodontic therapy (D0364, D3332) provided on October 3, 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 cone 
beam computed tomography (CT) scan and endodontic therapy (D0364, D3332) provided on October 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services. The Plan 
denied your request. The Plan says there is no authorization on file for the services provided. 
 
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 September 14, 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 - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on October 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency because you had a 
capped tooth break. You also say that the dentist needed to see the x-rays to determine the proper procedure to 
repair your tooth. The Plan denied your request. The Plan says your benefit for the requested item or service 
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 benefit for the limited oral evaluation - problem focused (D0140) was exhausted on date of service 
July 13, 2022, and the intraoral - periapical first radiographic image (D0220) on date of service June 30, 2021. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140), and intraoral - periapical first radiographic image (D0220) provided on October 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the x-ray of the swallowing function (74230) and 
x-ray of the upper gastrointestinal tract (74240) provided on September 2, 2022. 
 
You asked the Plan to pay for the x-ray of the swallowing function and x-ray of the upper gastrointestinal tract. 
You say that the services provided were medically necessary. The Plan denied your request. The Plan says 
these services were performed at a nursing home, which is denied as an excluded place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures involving fluoroscopy and procedures 
involving the use of contrast media are not covered under the portable x-ray provision. 
 
We looked at the file and Medicare rules. The services provided were for a barium swallow study in the 
portable mobile radiology setting. That imaging requires both the use of fluoroscopy and contrast. Based on 
this information, we decided that Medicare rules for coverage of the x-ray of the swallowing function and x-ray 
of the upper gastrointestinal tract have not been met. Therefore, we decided that the Plan does not have to pay 
for the x-ray of the x-ray of the swallowing function (74230) and x-ray of the upper gastrointestinal tract 
(74240) provided on September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and intraoral imaging 
(D0210) provided on August 19, 2022. 
 
You asked the Plan to pay for dental services. You say that you called and verified these services were covered. 
The Plan denied your request. The Plan says the rendered dental services are not covered 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 (D0140), and intraoral imaging (D0210) provided on August 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a blepharoplasty. 
 
You asked the Plan to pre-approve a blepharoplasty. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that any procedure(s) involving blepharoplasty and billed 
to this contractor must be supported by documented patient complaints which justify functional surgery. This 
documentation must address the signs and symptoms commonly found in association with ptosis, pseudoptosis, 
blepharochalasis and/or dermatochalasis.   
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 blepharoplasty. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the visual field testing is not reliable 
(fixation monitor off, high false negatives), does not correspond with the photos provided, and does not 
accurately demonstrate loss of 12 degrees or 30 % loss of upper field vision. The patient's initial complaints of 
blurry vision / difficulty driving was attributed to the cataracts and cataract surgery was planned. Subsequently, 
there is no documentation that the patient's symptoms persisted after the cataract surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a blepharoplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a blepharoplasty.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on 
September 08, 2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you previously had a 
mammogram  and were advised to return. You say that you should not have to pay for this test. 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 $90 
copayment for outpatient diagnostic tests and therapeutic services and supplies (diagnostic mammography). 
 
You have been asked to pay a $90 copayment for the breast ultrasound. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies (diagnostic mammography) 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. Please note that there were 
abnormal findings from the previous mammogram. This makes the ultrasound diagnostic in nature. Therefore, 
we decided that the Plan does not have to waive the copayment for the breast ultrasound provided on 
September 08, 2022.