Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 20, 
2022. 
 
You asked the Plan to pay for the limited oral evaluation. 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 limited 
oral evaluation (D0140) provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0120), intraoral radiographic images 
(D0220), and bitewings (D0274) provided on September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental office is close to you, and you did not 
know they were not a participating provider. 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 an oral evaluation (D0120), intraoral radiographic images (D0220), and bitewings (D0274) provided 
on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the glasses purchased on July 16, 2022. 
 
You asked the Plan to pay more for the glasses. You say that you were advised the treating provider was in-
network. The Plan denied your request. The Plan says this claim processed correctly. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 
 
 
 We looked at the file and the Plan's rules. The 2022 Evidence of Coverage clearly states that you are 
responsible for any amount over the $300 retail price for eyewear. The record shows that the retail price of the 
submitted charge is $523.00. After deducting the $300.00 allowance, $223.00 remains. You also receive a 20% 
discount, leaving you responsible for a total of $178.40 for the glasses. Based on this information, we decided 
that the Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not 
have to pay more for the glasses purchased on July 16, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 10, 2022.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met.
Maximus overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan noted that the enrollee had Tempus Gene Panel testing billed with multiple CPT codes, including 81232. This one code was submitted on its own on a separate claim form; the other codes were submitted on a different claim form, but testing was performed on the same specimen. Medicare denies coverage when a laboratory assay two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Additionally, modifiers should not be used to report multiple codes when a single specimen is tested. This testing was done on a single blood/tissue specimen. Finally, the claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on February 25, 2022, rather than the billed date of service March 10, 2022.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim could not be paid as billed due to issues with the date of service reported and multiple claims submitted for one specimen being testing. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 09, 
2022, to July 11, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you cannot afford this 
charge. 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 $370 
copayment for Inpatient hospital care. 
 
You have been asked to pay a $370 copayment for inpatient hospital stay. 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. You have been asked to pay $740 ($370 x 2 nights) copayment for your inpatient hospital 
stay. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay 
provided on July 09, 2022, to July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dentures (D5421, D5422) provided on May 23, 2022. 
 
You asked the Plan to pay for the dentures. 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 dentures 
(D5421, D5422) provided on May 23, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on September 02, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be covered. 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 $30 
copayment for Diagnostic procedures and tests. 
 
You have been asked to pay a $30 copayment for ultrasound. This item/service falls within the Diagnostic 
procedures and tests 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 ultrasound provided 
on September 02, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 27, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $45 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $45 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on September 27, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the SelectMDx testing provided on August 25, 2022. 
 
You asked the Plan to pay for the SelectMDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 denied payment for the laboratory services based on lack of 
documentation showing that Medicare criteria have been met. However, there is no evidence in the case file 
that records were requested from the ordering provider. Therefore, we decided that the Plan has to pay for the 
SelectMDx testing provided on August 25, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025) and progressive lenses (V2781) 
provided on September 26, 2022. 
 You asked the Plan to pay for deluxe frames (V2025) and progressive lenses (V2781). You say that you used 
an out-of-network provider due to the in-network provider's excessive prices. The Plan denied your request. 
The Plan says this provider is outside of the members network of providers and prior authorization was not 
obtained from the Plan. The Plan also says there is also no documentation that this member was referred to this 
non-contracted provider by a contracted provider, and no indication that any attempt was made to obtain prior 
authorization for the rendered services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when you use a doctor within their vision network. 
 
We looked at the file and the Plan's rules. The Plan rules say you must use a doctor in their vision network. The 
record shows the provider you used was not in the Plan's vision network. Based on this information, we 
decided that the Plan's rules for coverage of deluxe frames (V2025) and progressive lenses (V2781) have not 
been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025) and progressive 
lenses (V2781) provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a problem focused oral evaluation (D0140) provided on 
August 31, 2022. 
 
You asked the Plan to pay for the dental service. You say that you thought the enrollee would only have a 
specialist copayment and not an extra charge. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the problem focused oral evaluation is not covered by the Plan. 
 
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 problem 
focused oral evaluation (D0140) provided on August 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim maxillary partial denture (D5820) provided by an 
out-of-network provider on September 8, 2022. 
 
You asked the Plan to pay for an interim maxillary partial denture. You say that if you would have known the 
Plan would not pay anything, you would not have gotten these dentures. The Plan denied your request. The 
Plan says the rendered dental service 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 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 an interim 
maxillary partial denture (D5820) provided by an out-of-network provider on September 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care visit provided on May 17, 
2022, to June 5, 2022. 
 
You asked the Plan to waive the copayment for urgent care visit. 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 $15 
copayment per visit for urgently needed services.  
 
You have been asked to pay a $15 copayment per visit for urgent care visit. The total amount you are being 
asked to pay is $30 ($15 x 2visits = $30). 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 visit provided on May 17, 2022, to 
June 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care June 27, 2022, to 
June 29, 2022 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $25 
copayment for inpatient hospital care.  
 
You have been asked to pay a $25 copayment for 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. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
hospital care June 27, 2022, to June 29, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 2, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
roommate called 911 when they came home and found you unresponsive due to a diabetic incident. The Plan 
denied your request. The Plan says this service is not covered under your contract under any normal 
circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 2, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 28, 2022. 
 
You asked the Plan to pay for the panoramic x-ray. 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 June 30, 2022. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT scan (D0367) provided on April 5, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. 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 CT scan (D0367) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 8, 2022. 
 
You asked the Plan to pay for the occlusal guard. You say that you would like to be reimbursed the balance of 
$181.37 for the occlusal guard. The Plan denied your request. The Plan says this service is not covered, even 
when rendered by a participating 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. Therefore, we decided that the Plan does not have to pay for the 
occlusal guard (D9944) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92014) and a determination of 
refractive state (92015) provided on August 15, 2022.  
You asked the Plan to pay for a medical eye examination (92014) and a determination of refractive state 
(92015). You say that you did not know that your primary care provider (PCP) had submitted a claim for a 
routine eye examination and refraction on July 18, 2022. You also say that you went to your PCP due to a 
white spot in your eye, which turned out to be a calcium deposit. The Plan denied your request. The Plan says 
the member was provided an eye refraction on July 18, 2022, which exhausted the benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when one routine eye examination per calendar year. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one routine eye examination per 
calendar year. The record shows that this benefit was exhausted on July l8, 2022. Based on this information, we 
decided that the Plan's rules for coverage of a medical eye examination (92014) and a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
medical eye examination (92014) and a determination of refractive state (92015) provided on August 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and eye imaging provided on December 01, 
2021. 
 
You asked the Plan to pay for the office visit and eye imaging. You say that your PCP referred you to this 
provider. 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). The referring provider in this case is also not a network provider. Therefore, we 
decided that the Plan does not have to pay for the office visit and eye imaging provided on December 01, 2021.