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

 
We decided that the Plan does not have to waive the copayment for urgent care provided on September 18, 
2022. 
 
You asked the Plan to waive the copayment for urgent care. You say that you are disputing the share 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 $45 
copayment for urgently needed services.  
 
You have been asked to pay $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 provided on 
September 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 25, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was necessary because you had 
a toothache. 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 the date of service of March 21, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 25, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the cervical 
spine. 
 
You asked the Plan to pre-approve the MRI. You say that it is medically necessary for the enrollee to get an 
MRI done. The Plan denied your request. The Plan says the enrollee has not completed 6 weeks of provider 
directed treatment and the provider directed treatment did not occur within the last 3 months; therefore, the 
guidelines for an MRI were not met. 
 
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 the MRI. Our reviewer says that the 
MRI of the cervical spine is not medically reasonable or necessary. Our physician reviewer found that in this 
case the enrollee's neurological exam is normal and that the enrollee has not undergone any course of physical 
therapy. In addition, the enrollee's symptoms have improved with Gabapentin. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88365 billed for date of 
service May 4, 2022. 
 You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
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 codes 88342 and 88365 are column II codes to column I code 88321. The 
codes have not been billed with an appropriate modifier to bypass the edit. Because primary code 88342 is not 
covered, the add-on code 88341 is also not covered. 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 
codes 88341, 88342, and 88365 billed for date of service May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy (97802, 97803). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that the requested services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested services are not 
covered. 
 
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 pre-approve medical nutrition therapy (97802, 97803).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a caries risk assessment and documentation (D0602), an 
adult prophylaxis (D1110), and a periodic oral evaluation (D0120)  provided on October 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that your dentist and you both agree that your teeth 
should be cleaned four times a year due to calcium buildup. The Plan denied your request. The Plan says your 
benefit for an adult prophylaxis (D1110), and a periodic oral evaluation (D0120) has already been exhausted. 
The Plan also says that there is no coverage for a caries risk assessment and documentation (D0602). 
 
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. A caries risk 
assessment and documentation (D0602) are not among those covered under this benefit. Also, certain 
limitations apply to this dental benefit the Plan offers. The record shows your benefit for an adult prophylaxis 
(D1110), and a periodic oral evaluation (D0120) was exhausted on date of service February 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a caries risk assessment and documentation 
(D0602), an adult prophylaxis (D1110), and a periodic oral evaluation (D0120)  provided on October 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection provided on July 27, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that you feel 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 $285 
copayment for in-network Medicare-covered surgical services performed in an outpatient department of a 
hospital or in an ambulatory surgical center. 
 
You have been asked to pay $281.12, which is less than the standard $285 copayment for an injection. This 
injection falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical center 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 injection 
provided on July 27, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 27, 2022, 
to March 21, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 27, 2022, to 
March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body tooth #'s 03, 19, 21 
(D6010), bone graft at time of implant placement tooth #'s 03, 19, 21 (D6104), drugs or medicaments dispensed 
in the office for home use (D9630), guided tissue regeneration tooth #'s 03, 19, 21 (D4266), and guided tissue 
regeneration (D0330) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of $7909, the 
payment you made to the provider. The Plan denied your request. The Plan says these services are not covered 
under the benefit package and you were charged the correct 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. 
 
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, and the (D0330) service was received from an out-of-network 
provider. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body 
tooth #'s 03, 19, 21 (D6010), bone graft at time of implant placement tooth #'s 03, 19, 21 (D6104), drugs or 
medicaments dispensed in the office for home use (D9630), guided tissue regeneration tooth #'s 03, 19, 21 
(D4266), and guided tissue regeneration (D0330) provided on August 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on April 22, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. 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 office visit provided on 
April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) and jaw x-ray (70355) provided on 
April 11, 2022, by a Medicare opt-out provider. 
 
You asked the Plan to pay for the physician services. You say that even though the provider has opted out of 
Medicare, some of the charges should have been covered by out-of-network coverage. The Plan denied your 
request. The Plan says payment cannot be made for services performed by a provider that has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and jaw x-ray 
(70355) provided on April 11, 2022, by a Medicare opt-out provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 5, 2022, to 
March 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 5, 2022, to 
March 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ReActiv8 restorative neurostimulation device. 
 
You asked the Plan to pre-approve a ReActiv8 restorative neurostimulation device. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
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 a ReActiv8 restorative neurostimulation 
device. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is considered experimental and more research is needed to show 
safety and efficacy. 
 
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 ReActiv8 restorative neurostimulation device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a ReActiv8 restorative neurostimulation device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment (D6056), an abutment supported 
crown (D6059), and a prefabricated post and core (D2954) provided on February 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you want the Plan to pay for the services. The 
Plan denied your request. The Plan says the services at issue 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 
prefabricated abutment (D6056), an abutment supported crown (D6059), and a prefabricated post and core 
(D2954) provided on February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intraosseous ablation of the basivertebral nerve with 
the Intracept procedure (64628). 
 
You asked the Plan to pre-approve an Intraosseous ablation of the basivertebral nerve with the Intracept 
procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the 
service is not medically necessary. 
 
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 an Intraosseous ablation of the 
basivertebral nerve with the Intracept procedure. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found documentation 
was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies 
as being the overwhelming primary generators of the enrollees chronic persistent pain. Documentation does 
not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary 
and/or reasonable at this time. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
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 Intraosseous ablation of the basivertebral nerve with the Intracept procedure 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intraosseous ablation 
of the basivertebral nerve with the Intracept procedure (64628).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extractions of tooth #18, 22, 23, 24, 25, 26, 27, 
and 28 (D7210) and alveoloplasty in the lower right and lower left quadrants (D7310) provided on April 25, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says surgical extractions (D7210) and alveoloplasty (D7310) are not 
covered by 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 the 
surgical extractions of tooth #18, 22, 23, 24, 25, 26, 27, and 28 (D7210) and alveoloplasty in the lower right 
and lower left quadrants (D7310) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A9279, S1015 and S8301 billed for date of 
service July 18, 2022. 
 
You asked the Plan to pay for procedure codes A9279, S1015 and S8301. You say that you would like to 
appeal this denial. 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 codes A9279, S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes A9279, S1015 and S8301 are not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of procedure codes A9279, S1015 and 
S8301 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes A9279, 
S1015 and S8301 billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 27, 2022. 
 
You asked the Plan to pay for the office visit. You say that you went for a COVID-19 test and no exam was 
performed. 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 the office visit provided 
on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit, intralesional injection, and triamcinolone 
acetonide provided on March 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the claim should be reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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, intralesional injection, and triamcinolone 
acetonide provided on March 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) and computed tomography (CT) of 
the head or brain (70450) provided on April 1, 2022. 
 You asked the Plan to pay for the chest x-ray and CT of the head or brain. You say that you feel these services 
were not processed correctly due to a system error. The Plan denied your request. The Plan says the member 
was enrolled in hospice on this date of service. The Plan also says this bill should be sent to Original Medicare. 
 
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 chest x-ray (71045) and computed tomography (CT) of 
the head or brain (70450) provided on April 1, 2022.