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

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 5, 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 testing is 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, a cardiac risk assessment panel, 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 rendered on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavior management, by report (D9920) and 
unspecified adjunctive procedure, by report (D9999) provided December 13, 2021. 
 
You asked the Plan to pay for the behavior management and unspecified adjunctive procedure. You say that 
you feel you are due additional payment. The Plan denied your request. The Plan says these services are not 
covered under your benefits. 
 
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. Therefore, we decided that the Plan does not have to pay for the behavior management, by report (D9920) and unspecified adjunctive procedure, by report (D9999) provided December 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a detailed and extensive problem focused oral evaluation 
(D0160) and other temporomandibular joint radiographic images (D0321) provided on October 28, 2021. 
 
You asked the Plan to pay for a detailed and extensive oral evaluation and other temporomandibular joint 
radiographic images. You say that you do not agree with the denial of charges. You would like to request 
reimbursement. The Plan denied your request. The Plan says the requested services are not listed as covered 
procedures with your Plan. 
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. Therefore, we decided that the Plan does not have to pay for a detailed 
and extensive problem focused oral evaluation (D0160) and other temporomandibular joint radiographic 
images (D0321) provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  first 15 minutes 
(D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve deep sedation/general anesthesia. You say that the enrollee needs the 
sedation for the dental procedure. The Plan denied your request. The Plan says the anesthesia is not covered 
because it will be associated with a non-covered procedure. 
 
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 dental benefits in excess of Medicare coverage, the deep sedation/anesthesia is not 
among those covered services. Therefore, we decided that the Plan does not have to pre-approve deep 
sedation/general anesthesia  first 15 minutes (D9222) and deep sedation/general anesthesia  each subsequent 
15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay up to the eyewear benefit allowance of $300 for eyeglasses provided on 
November 12, 2021. 
 
You asked the Plan to pay up to the eyewear benefit allowance of $300 for the eyeglasses. You say that you 
were told by the provider that you would not owe any money and there was a mistake somewhere. The Plan 
denied your request. The Plan says that the claim processed in-network with a $100 member responsibility. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services with a $300 allowance in and out-of-network.  
 
We looked at the file and the Plan's rules. The file shows that the Plan covers an eyewear benefit with a $300 
allowance in and out-of-network. Therefore, we decided that the Plan has to pay up to the eyewear benefit 
allowance of $300 for eyeglasses provided on November 12, 2021.  
 
 
 
 
 
 
 
 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone density study provided on December 27, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for bone density study. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services were 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 bone density study provided on December 27, 
2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
July 28, 2021, to August 18, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that services were given due 
to medical error, not for any planned surgery. You also say that you should not have to pay these bills. The 
Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
 
 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 $295 
copayment per admission for an inpatient hospital stay.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$295 copayment for an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay 
provided from July 28, 2021, to August 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on 
January 6, 2022. 
 
You asked the Plan to pay for the dental service. You say that this was medically necessary. The Plan denied 
your request. The Plan says a comprehensive oral evaluation is covered once every 3 plan years. The Plan also 
says that the frequency limit has been exceeded. 
 
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 and a comprehensive oral evaluation is 
covered once every 3 plan years, the frequency limit has been exceeded.  
The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 13, 
2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on October 1, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the telehealth visit. You say that it was medically necessary to treat the enrollee 
and you would like the claim reprocessed for payment. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from an in-network provider or an 
approved authorization. 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 a telehealth visit provided on October 1, 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 problem focused limited oral evaluation (D0140) 
provided on December 27, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not understand 
how there can be a frequency limitation when problems arise. You also say that you would like this service to 
be reconsidered for coverage because this was not a cleaning or routine exam. The Plan denied your request. 
The Plan says this service exceeds the frequency limitation in your benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on December 13, 2021 and your problem focused limited oral 
evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the problem focused limited oral evaluation (D0140) provided on December 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on December 8, 2021. 
 
You asked the Plan to pay for the dental service. You say that the office contacted your plan prior to your 
appointment. You also say that you were informed that the procedure would be covered in full. The Plan 
denied your request. The Plan says scaling in presence of generalized moderate or severe gingival 
inflammation 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 scaling in presence of generalized 
moderate or severe gingival inflammation is not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival 
inflammation (D4346) provided on December 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 12, 2020. 
 
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. 
 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 rendered on November 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a walking boot provided on October 8, 
2021. 
 
You asked the Plan to waive the coinsurance for the walking boot. You say that you do not know why you 
received a bill for the walking boot. The Plan denied your request. The Plan says the correct coinsurance was 
applied. 
 
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 20% 
coinsurance for durable medical equipment (DME) items and supplies, including walking boots.  
 
You have been asked to pay $62.25, which is 20% of the allowed amount for the walking boot ($311.25 allowed amount x 20% coinsurance = $62.25). The walking boot falls within the Durable Medical Equipment 
(DME) and Related 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 coinsurance for a walking 
boot provided on October 8, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GeneSight Psychotropic Assay rendered on December 4, 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 that the criteria for coverage are not met. 
 
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 states the testing does not meet the criteria for coverage in Local 
Coverage Determination (LCD)  L36533. This LCD was retired on July 25, 2020 and was therefore not binding 
for the date of service at issue. Furthermore, this LCD is not binding for the state of Ohio where the single-
source testing is performed. The Plan has not provided any documentation or valid Medicare rules to support 
that the testing is not covered. Therefore, we decided that the Plan has to pay for the GeneSight Psychotropic 
Assay rendered on December 4, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on December 28, 2021. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was medical vision check (Age-related nuclear cataract, left eye). Eye 
refractions are only covered by your Plan if performed by a participating provider and performed as a routine 
screening per your 2021 Evidence of Coverage. 
 
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state 
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered 
diagnosis or treatment of illness or injury.  
 
 
 
  
 
 
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the 
Plan does not have to pay for an eye refraction provided on December 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 29, 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 were not billed correctly. 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the retainer crowns (D6750 x 2) and pontic (D6240) provided on 
September 23, 2021. 
 
You asked the Plan to pay for the dental services. You say that your bridge needed to be repaired or replaced. 
You say that you feel replacing the teeth with a bridge would be less costly than dentures. You also say that 
you had your previous bridge for over 40 years. The Plan denied your request. The Plan says that the 
information received for the appeal did not tell us why you could not use a denture to replace your missing 
teeth, the services were denied because the provided narrative failed to indicate or support any specific physical 
or psychological conditions that preclude the use of a removeable prosthesis. 
 
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 the dental 
services 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 pay for the dental services. Our reviewer says that 
the fixed bridge is not medically necessary. Our physician reviewer found the removal of the current defective 
bridge would require new crowns on the abutments # 6 and 11. The reviewer found that a new bridge is the 
most reasonable replacement. The documentation provided meets the criteria for coverage for a fixed bridge to 
replace the defective bridge replacing missing tooth # 10 using teeth # 9 and 11 as abutment retainers. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pay for the retainer crowns (D6750 x 2) and pontic (D6240) provided on September 23, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound provided on November 16, 2021. 
 
You asked the Plan to pay for an ultrasound. The Plan denied your request. 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 Plan says that the Plan has 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an ultrasound provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination and 
evaluation provided by a medical professional on November 23, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says it is important to know which providers are part of our network because, with 
limited exceptions, while you are a member of our Plan you must use network providers to get your medical 
care and services. The only exceptions are emergencies, urgently needed services when the network is not 
available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes use of out-of-network providers. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation 
provided on November 23, 2021.