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

 
We decided that the Plan does not have to pay for drug testing provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You submitted medical records to support medical necessity. 
The Plan denied your request. The Plan says authorization was not obtained prior to services being 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 drug testing provided on February 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
June 2, 2022. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI). You say that you would 
like to appeal the cost share. 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 $175 
copayment for magnetic resonance imaging (MRI).  
 
You have been asked to pay a $175 copayment for magnetic resonance imaging (MRI). 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 magnetic resonance imaging (MRI) on June 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on April 28, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before 
the service was 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 provider in this case is not a network provider with the Plan. 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 office visit (99204) provided on April 28, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 
06, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel this was COVID-
19 related and you should not have a 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 $40 
copayment for specialist office visit. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the 
specialist office visit 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 specialist office 
visit provided on June 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on 
April 30, 2022, to May 05, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that your booklet shows 
you do not have to pay for anything under 60 days. 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 
$1,736.05 copayment for inpatient hospital care. 
 
You have been asked to pay a $1,736.05 copayment for the inpatient hospital 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. The EOC says there is a $350 copayment per day for the first 5 days of inpatient 
care. Your stay lasted 5 days for a total of $1,750. However, you are only responsible for $1,736.05 due to 
meeting your out-of-pocket maximum. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital care provided on April 30, 2022, to May 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care on July 20, 2022. 
 
You asked the Plan to waive the copayment for urgent care. 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 $45 
copayment per visit for covered services to a medical facility or urgent care center. Urgently needed services 
are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate 
medical care. Urgently needed services may be furnished by network providers or by out-of-network providers 
when network providers are temporarily unavailable or inaccessible. 
 
You have been asked to pay a $45 copayment for urgent care. This item/service falls within the Urgently 
needed 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 urgent care on July 20, 
2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 16, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
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 the subsequent nursing facility care (99309) provided on May 
16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on July 12, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for closed treatment of distal radial fracture (25605) provided 
May 8, 2021. 
 
You asked the Plan to pay for the procedure. You say that you disagree with the determination and based on 
CPT and/or CMS guidelines you believe this service was appropriately billed. Please see attached medical records to support the visit. The Plan denied your request. The Plan says the records do not support the service 
billed. 
 
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 25605-54 is closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed, with manipulation. 
 
We find that CPT code 25605-54 is not supported in the medical record. Specifically, the records do not 
include documentation to support that closed treatment of distal radial fracture or epiphyseal separation, 
includes closed treatment of fracture of ulnar styloid, when performed, with manipulation was performed. 
There is a more appropriate CPT code (25600: closed treatment of distal radial fracture or epiphyseal 
separation, with or without fracture of ulnar styloid; without manipulation) for the services provided. The Plan 
made multiple attempts to contact the provider for additional information. Based on this information, we 
decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the 
Plan does not have to pay for closed treatment of distal radial fracture (25605) provided May 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown on tooth #5 (D6740) and core build up 
on tooth #5 (D2950). 
 
You asked the Plan to pre-approve a crown and core build up. You say that these services are medically 
necessary. The Plan denied your request. The Plan says there is no completed root canal on tooth #5. 
 
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 crown and 
core build up 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 crown and core build up. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found a review of the 
documentation indicates that tooth #5 has deep caries requiring a root canal. Evidence of the completion of the 
root canal is required prior to approval of the core build up and crown. 
 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 crown and core build up have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a retainer crown on tooth #5 (D6740) and core build up on tooth #5 (D2950).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the enrollee is in severe pain and the 
clinical information provided supports the need for the services in dispute. The Plan denied your request. The 
Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery 
have not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 bone marrow aspirate. Our reviewer 
says that bone marrow aspirate is not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental, and more research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown fused to noble metal (D2752) for 
teeth numbers 24 and 25. 
 
You asked the Plan to pre-approve a porcelain crown fused to noble metal (D2752) for teeth numbers 24 and 
25. You say that the crown was denied, but they took better x-rays and resubmitted supporting records. The 
Plan denied your request. The Plan says per the EOC, a porcelain crown fused to noble metal (D2752) for teeth 
numbers 24 and 25 is denied due to there is no evidence of decay or missing crown to support the need for 
replacement. 
 
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 porcelain 
crown fused to noble metal (D2752) for teeth numbers 24 and 25 when the services are medically necessary 
and reasonable.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a porcelain crown fused to noble metal 
(D2752) for teeth numbers 24 and 25. Our reviewer says that this is not medically necessary. Our physician 
reviewer found the documentation provided does not meet the criteria for coverage for a porcelain crown fused 
to noble metal (D2752) for teeth numbers 24 and 25. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a porcelain crown fused to noble metal (D2752) for teeth numbers 24 and 25. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown fused to 
noble metal (D2752) for teeth numbers 24 and 25.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan has to pay for prophylaxis and an oral examination provided by a participating 
provider on September 13, 2022. 
 
You asked the Plan to pay for prophylaxis and an oral examination. You say that you would like the Plan to 
pay for this. The Plan denied your request. The Plan says that the benefit limit for the services provided have 
already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has failed to provide and Explanation of Benefits for date of service 
March 8, 2022. Therefore, we decided that the Plan has to pay for prophylaxis and an oral examination 
provided by a participating provider on September 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 31622 provided on date of service March 16, 
2022. 
 You asked the Plan to pay for procedure code 31622. You say that the medical records show medical necessity. 
The Plan denied your request. The Plan says no modifiers are allowed with this code pair. 
 
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 31622 is a column II code to column I code 31625 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on this information, we decided that the 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 31622 provided on date of service March 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intra-oral x-ray (D0150, 
D0210) provided on July 28, 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 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 requested item or service was exhausted on date of service September 28, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation and intra-oral x-
ray (D0150, D0210) provided on July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulmonary rehabilitation services (94625, 94626). 
 You asked the Plan to pre-approve the pulmonary services. You say that you need pulmonary rehabilitation to 
strengthen your lungs and diaphragm and it would make your quality of life better The Plan denied your 
request. The Plan says the records do not support medical necessity for pulmonary rehabilitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 the pulmonary services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has progressive interstitial lung disease. Medicare covers pulmonary 
rehabilitation for patients with moderate to severe COPD or for lung transplantation. Neither applies to this 
enrollee. Spirometry shows only mild impairment of the FEV1. The denial is upheld. Pulmonary rehabilitation 
is considered not medically necessary because Medicare criteria are not met.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pulmonary services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the pulmonary rehabilitation services (94625, 94626).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 82565 and 84315 provided on March 14, 2022. 
 
You asked the Plan to pay for codes 82565 and 84315. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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. 
 
 We find that CPT codes 82565 and 84315 are not supported in the medical record. Specifically, the medical 
records do not include a physician order or laboratory requisition for the billed test coded 82565. The medical 
records indicate that urine was collected. There is a more appropriate code to be billed for the service provided; 
therefore, code 84315 is not supported. Based on this information, we decided that Medicare rules for coverage 
of codes 82565 and 84315 have not been met. Therefore, we decided that the Plan does not have to pay for 
codes 82565 and 84315 provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on February 2, 2022, to March 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
overpayment audit findings. 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 the dental services on February 2, 2022, to March 28, 2022.