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

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on May 6, 2021. 
 
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 the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on May 6, 2021.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the column chromatography and mass spectrometry provided 
with drug testing on February 5, 2021. 
 
You asked the Plan to pay for the column chromatography and mass spectrometry. You say that this should be 
paid. The Plan denied your request. The Plan says the drug testing was approved for payment, but no separate 
payment is made for the validity testing. 
 
The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for specimen 
validity testing provided with a drug test.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the column chromatography and mass spectrometry have not been met. Therefore, we decided that 
the Plan does not have to pay for the column chromatography and mass spectrometry provided with drug 
testing on February 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EGD, flexible, transoral; with directed submucosal 
injection(s), any substance (CPT code 43236) and the EGD, flexible, transoral; with control of bleeding, any 
method (CPT code 43255) provided on May 6, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as 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. NCCI PTP edit exists between 43239 and 43236 
and between 43239 and 43255. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are 
allowed, however, an appropriate NCCI modifier was not billed with this PTP code 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 the EGD, flexible, transoral; with directed submucosal injection(s), any substance (CPT code 43236) 
and the EGD, flexible, transoral; with control of bleeding, any method (CPT code 43255) provided on May 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone (G2067) provided 
on June 21, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment, methadone. You say that a previous call to the 
Plan told you that no authorization is needed if you are in-network. You also say that you are now enrolled 
going back to March 1, 2021, and services need to be billed to the primary Medicare carrier. The Plan denied 
your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 medication assisted treatment, methadone (G2067) 
provided on June 21, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical first radiographic image (x-ray) 
(D0220), provided on November 8, 2021. 
 
You asked the Plan to pay for the x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 the 
intraoral periapical first radiographic image (x-ray) (D0220), provided on November 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 1, 2021, and August 4, 2021. 
 
You asked the Plan to pay for dental services. You say that you were aware that you would have a 30% 
coinsurance. You say that you were not seen by this dentist, you were seen by a dental hygienist. The Plan 
denied your request. The Plan says the dentist that provided these services is an opt-out provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Services provided by an opt-out provider or the associated office are 
processed as an opt-out provider. Therefore, we decided that the Plan does not have to pay for dental services 
provided by an opt-out provider on February 1, 2021, and August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused exam (D0140) provided on October 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you were not advised this service would not be 
covered. The Plan denied your request. The Plan says problem focused exam 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the problem focused exam is not 
among those covered under this benefit. Additionally, the record shows that you signed a treatment plan 
estimate showing that this service would not be covered. Therefore, we decided that the Plan does not have to 
pay for the problem focused exam (D0140) provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the partial lower denture (D5213) and immediate 
upper denture (D5130) provided on August 25, 2021. 
 
You asked the Plan to reimburse you for the dental services. You say that the in network dentist you were given 
by the plan wanted to send you to a specialist where no one accepted your insurance plan. You say that the 
dental office advised there was no charge. You also say that you cannot afford to pay this bill. The Plan denied 
your request. The Plan says the provider in this case is out of network. The Plan says that out of network 
providers are paid based on the allowed amount. The Plan also says that you did not contact them to verify 
benefits or provider eligibility. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage ad dentures are listed as covered, there 
is a 75% coinsurance for dentures that you receive out of network. The record shows that the Plan paid 25% of 
the allowed amount for the dentures. Therefore, we decided that the Plan does not have to reimburse you for 
the partial lower denture (D5213) and immediate upper denture (D5130) provided on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on November 2, 2021. 
 
You asked the Plan to pay for the dental service. You say that this should be covered. The Plan denied your 
request. The Plan says complete series x-ray is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete 
series x-ray (D0210) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-intravenous sedation (D9248), extraction, erupted 
tooth or exposed root (D7140), osseous surgery (D4261 and D4260), and occlusal adjustment (D9943), 
provided on August 31, 2021. 
 
You asked the Plan to pre-approve non-intravenous sedation, extraction, erupted tooth or exposed root, osseous 
surgery, and occlusal adjustment. You say that the services were medically necessary. The Plan denied your 
request. The Plan says all Medicare-covered dental procedures require prior approval from the plan. In 
addition, the services billed are not coded as routine and do not have a cancer-related diagnosis. 
 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. Specifically, there was no prior approval for these services, and you do 
not meet the requirements for dental surgery. Therefore, we decided that the Plan does not have to pre-approve 
non-intravenous sedation (D9248), extraction, erupted tooth or exposed root (D7140), osseous surgery (D4261 
and D4260), and occlusal adjustment (D9943), provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7210), provided on October 14, 2021. 
 
You asked the Plan to pay for the extraction. You say that this service should be covered. The Plan denied your 
request. The Plan says you obtained this service out of network. 
 
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. Specifically, you obtained this service out-of-network. This means you 
are responsible for the difference between what the out-of-network provider charged and what an in-network 
provider would have charged. Therefore, we decided that the Plan does not have to pay for the extraction 
(D7210), provided on October 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) and psychotherapy 
(90837) provided on July 21, 2021, to July 28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation and psychotherapy. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says the rendering provider is 
non=participating with the Plan and the facility is also non-participating. The Plan also says that there is not a 
referring provider and there is no evidence that this is 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 psychiatric diagnostic evaluation (90791) and 
psychotherapy (90837) provided on July 21, 2021, to July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the doctor will not put a referral in for labs 
and they are not required. The Plan denied your request. The Plan says the rendering and referring providers 
are both out-of-network providers. 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 laboratory services provided on November 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery has 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no specific 
indication provided to support the request for bone marrow aspirate for the approved surgery. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone 
marrow aspiration in conjunction with the planned cervical spine surgery.  There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow  aspirate for this enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve bone marrow aspirate for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentures (D7140), provided on August 11, 2021, to 
August 17, 2021. 
 
You asked the Plan to pre-approve the dentures. You say that the service should be covered. The Plan denied 
your request. The Plan says non-network dentists have not agreed to provide services at contracted fees. If the 
member is to see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-
network fee schedule (INFS) in their area. The member is responsible for the difference between the INFS and 
dentists' charged fees when visiting an out-of-network dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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. Specifically, you received services through an out-of-network 
provider. This means you are responsible for the difference between what an in-network provider would have 
charged and the amount the out-of-network provider charged. Therefore, we decided that the Plan does not 
have to pre-approve the dentures (D7140), provided on August 11, 2021, to August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 21, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered.  
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 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 laboratory 
services provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and extraction (D7210) 
provided from October 5, 2021, to October 26, 2021 by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that the plan paid nothing for the periodontal 
maintenance. You say that the plan only paid $46.25 for the extraction. The Plan denied your request. The Plan 
says periodontal maintenance is covered twice per calendar year. The Plan says that the frequency limit has 
been exceeded.  The Plan also says there is a 50% coinsurance of covered plan allowance for major dental services, including 
extraction. The Plan also says that dental services you receive out of network may cost more. 
 
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 and the services are listed as covered, 
they have limitations. Periodontal maintenance is covered twice per calendar year, but the frequency limit has 
been exceeded. The record shows that the Plan paid for periodontal maintenance that you received on January 
12, 2021, and May 25, 2021. Additionally, the Evidence of Coverage says you pay a 50% coinsurance of the 
covered plan allowance for major dental services, including extractions. The record shows that the plan paid 
$46.25, or $92.50 x 50%. Additionally, out of network providers may bill you the difference between what they 
bill you and what the plan pays the provider. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) and extraction (D7210) provided from October 5, 2021, to October 26, 2021 
by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ophthalmology services provided on 
October 12, 2021. 
 
You asked the Plan to waive the copayment for the ophthalmology services. You say that the services should 
be covered in full as you were called a bad customer and your copayment was refunded. The Plan denied your 
request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
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 Vision care.  
 
 
  You have been asked to pay a $45 copayment for ophthalmology services. Ophthalmology services fall within 
the Vision care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for ophthalmology services 
provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (code D0140) you received on November 18, 
2021. 
 
You asked the Plan to pay for the oral exam. You say that you didn't know that you had exceeded the frequency 
for this service and you thought you would have enough to cover this service within the plan maximum. The 
Plan denied your request. The Plan says you have exceeded the annual frequency limit for this service.  
Records show that you already received an oral exam on May 5, 2021. 
 
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 the oral 
exam (code D0140) you received on November 18, 2021.