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

 
We decided that the Plan does not have to pay for laboratory services (99305, 88312) provided on November 4, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the doctor's office failed to send in a 
preauthorization form for approval. 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 laboratory services (99305, 88312) provided on 
November 4, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the travel mileage and lodging fees 
provided between April 5, 2021, and June 12, 2021. 
 
You asked the Plan to make additional payment for the travel mileage and lodging fees. You say that you 
believe that the total amount reimbursed was not correct. The Plan denied your request. The Plan says the 
travel mileage and lodging fees were reimbursed for the dates during which you were a candidate for a 
transplant. Some of the dates you were no longer being considered for the transplant, which means the lodging 
for those dates are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must cover travel and lodging fees when 
enrollees must travel further than normal patterns of care for transplant services.  
 
We looked at the file and Medicare rules. We find that for part of the time during which you claimed these fees, 
you were not a transplant candidate. Although the provider wished you to remain in the area, the Plan is not 
required to reimburse for this span of time. Based on this information, we decided that Medicare rules for 
coverage of the travel mileage and lodging fees have not been met. Therefore, we decided that the Plan does not have to make additional payment for the travel mileage and lodging fees provided between April 5, 2021, 
and June 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on May 
13, 2021. 
 
You asked the Plan to pay for the laboratory service. 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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81479 (1 Unit) 
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an off campus-outpatient hospital setting POS 19. It is noted multiple 
attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (CPT code 81479) provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81546) provided on September 16, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you submitted the statement of medical 
necessity for the diagnostic test ordered by the network physician with the appropriate code and the laboratory 
report with the indeterminate cytopathology diagnosis, which meets both requirements in the local coverage 
determination (LCD). You also say there are no other coverage requirements for the Afirma test and there is no 
prior authorization requirement for this service. The Plan denied your request. The Plan says the services were 
rendered and referred by non-participating provider and 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 laboratory services (81546) provided on 
September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 14, 2021 by an 
out-of-network (OON) provider. 
 
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 rendered by an out-of-network provider without prior authorization. 
 
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 referring provider 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 the laboratory services provided on October 14, 2021 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 (CPT code 71045) provided on November 4, 
2021. 
 
You asked the Plan to pay for the chest x-ray. 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. In this case, we have confirmed that code 71045 
is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to 
bypass the 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 chest x-ray (CPT code 71045) provided on November 4, 
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for breast surgery services provided on June 21, 2021.
You asked the Plan to pay for these services. You say that this surgery should be paid by the Plan. The Plan
denied your request. The Plan says you did not have prior authorization for this surgery. We overturned
the Plans denial for a lack of medical records submitted with the file.
The Plan requested a reopen and provided both medical records and additional information from your provider.
The Plan stated that the phone records show the Plan spoke to the staff at the providers office. The staff
indicated you did not mention a lumpectomy to your providers. They indicated you wanted a refund after you
had already paid for the surgery and wanted to submit to insurance. The staff stated that told you they would
have to cancel the appointment and submit a prior authorization. The staff stated they told you a reschedule
would be a few months out due to previously booked appointments. The staff stated you did not want to cancel
and kept the appointment and indicated you would submit to insurance on your own.
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 Plan only pays for breast reconstruction after a mastectomy.
You paid for surgery out of network and without Plan approval. The surgery provided is not covered under the
Plan benefit. 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 breast surgery provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for white fillings-three surfaces (D2393), amalgam-three 
surfaces (D2160) and extensive treatment planning (D9450) received October 26, 2021. 
 
You asked the Plan to pay for white fillings, amalgam-three surfaces and extensive treatment planning. You 
say that you chose the least expensive option, but the Plan is not covering it. The Plan denied your request. The 
Plan says the services processed according to the Plan contract. 
 
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, extensive treatment planning is not 
among those covered under this benefit.  The record shows that the white fillings were for three surfaces on a back tooth (tooth # 18). This means that the Plan processed the claim correctly and additional payment is not due at this time. Therefore, we decided that the Plan does not have to pay an additional amount for white fillings-three surfaces (D2393), amalgam-
three surfaces (D2160) and extensive treatment planning (D9450) received October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for deep sedation (codes D9222 and D9223).
You asked the Plan to cover deep sedation. You say that at the time of the appeal, deep sedation was medically
necessary. The Plan denied your request. The Plan says deep sedation is not a covered benefit. The IRE
overturned the Plans denial. The Plan requested a reopen stating the IRE did not apply the correct contract
criteria.
The Plan is correct in this case. Medicare does not cover dental services. For that reason, the Plan's coverage
rules apply in this case. The code for anesthesia in a dental setting is 00170. Anesthesia is listed as a covered
service in the Plan contract. The codes for deep sedation, which is a separate and distinct service, are D9222
and D9223. These are not listed as covered services in the Plan contract. Your provider asked for codes D9222
and D9223, which is not a covered benefit under the Plan dental contract. Therefore, we decided that the Plan
does not have to pre-approve deep sedation (codes D9222 and D9223) for dental services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for skilled nursing facility services
provided from May 7, 2021, to May 31, 2021.
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan
denied your request. The Plan says this cost share was charged based on the services provided and the Plan
contract agreement. We partially overturned the Plans denial. The Plan requested a reopen and stated you
were not discharged from the facility on May 31, 2021. The records show you were discharged from the skilled
nursing facility to outpatient observation on June 1, 2021. Therefore, the $100 copayment for May31,2021
would apply since it is not the day of discharge.
The Plan is correct in this case. 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 shows your cost share expectations for skilled nursing facility services. 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 copayments charged for skilled nursing facility services provided from May 7,
2021, to May 31, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided in the emergency room
from May 29, 2021, to May 30, 2021.
You asked the Plan to pay for self-administered drugs under Medicare Part B. You say that these drugs were
provided by the hospital and should be covered by the Plan. The Plan denied your request. The Plan says
payment for self-administered drugs provided by a facility must be submitted to the Part D carrier you were
covered by at the time of service.
When this case was denied by the Plan it was automatically sent to the Independent Review Entity (IRE) for
review. The IRE upheld the Plans decision. You then requested an ALJ hearing. The ALJ remanded the case
back to the IRE. The ALJ stated the case file lacked a list of the self-administered drugs provided to you on the
dates of service in question. The ALJ stated that because this information was missing from the written record
this case was remanded back to the IRE for second review.
The IRE reopened the appeal and performed an independent review of the case file. The IRE sent a request for
additional information to the Plan for a list of the self-administered drugs that were billed by the facility. In
response to the IRE's request, the Plan provided the following list of drugs billed on the claim and confirmed
that these drugs would not have been eligible for payment under Medicare Part B. Those drugs were as follows:
Belsomra - 5 mg Oral Bedtime
Colcrys - 0.6 mg Oral, Daily
Dexilant - 60 mg Oral Daily
Eliguis - Oral 5 mg Oral
Myrbetriq - Oral 50 mg
Prevlite Oral 4mg
Tresiba Flex Touch 200 Units Daily
Tylenol 500 mg Oral
Vitamin D2 50,000 oral capsule
Allopurinol - 300 mg
Amiodarone - 200 mg
Atenolol - 50 mg Oral
Clopidogrel - 75 mg oral
Colchicine - 0.6 mg oral
Fenofibrate - 145 mg oral
Finasteride - 5 mg oral
Fluticasone nasal
Gabapentin - 300 mg oral
Hydralazine - 50 mg
Nitroglycerin- 0.4 mg oral
Rosuvastatin -10 mg oral
Tamsulosin - 0.4 mg oral capsule
The IRE has concluded the upheld decision will stand. The Plan must follow Medicare rules. The rules say that
Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided are
not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have
to pay for self-administered drugs provided in the emergency room from May 29, 2021, to May 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin based composite (D2392) provided on October 21, 2021. 
 
You asked the Plan to pay for the resin based composite. You say that you would like reconsideration because 
this service should be a covered benefit. The Plan denied your request. The Plan says you are responsible for 
the difference between the allowed amounts, your deductible and coisurance. 
 
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. 
 
We looked at your request, the file and Plan rules. Based on this information, we have determined that this 
claim has processed correctly. Per your contract with the Plan indicates that you are responsible for the 
difference between the allowed amounts, the deductible and coinsurance. The records indicate that these have been applied appropriately. Therefore, we decided that the Plan does not have to pay for the resin based composite (D2392) provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for vision services provided on
January 5, 2021.
You asked the Plan to pay additional reimbursement for these services. You say that the Plan should cover
more of the cost of these services. We partially overturned the Plans denial. The Plan requested a reopen
and provided additional information. The Plan states that the total vision services provided were billed at
$606.40 by your vision provider. After application of the $200 maximum benefit, your responsibility was
$406.40. The records show you only paid $303.20. The Plan paid an additional $140 over the benefit limit as a
courtesy due to miscommunication by the provider.
The Plan is correct in this case. Medicare 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 contract says there is a $200 allowance for supplemental eyewear every year. The Plan has shown
they have actually paid the $200 allowance plus an additional $140 to the provider as a courtesy. Therefore, we
decided that the Plan does not have to pay additional reimbursement for vision services provided on January 5,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on November 4, 2021. 
 
You asked the Plan to pay for the prophylaxis. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says you have exhausted this 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 exceed 
the limit set by the Plan benefit. This service is covered twice per Plan year and the records show that you have 
already received a standard adult cleaning billed with CPT code D1110 twice. Therefore, we decided that the 
Plan does not have to pay for the prophylaxis (D1110) provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the cost share charged for outpatient services and
Medicare Part B drugs and administration provided on March 16,2021.
You asked the Plan to waive or reduce this cost share. You say that you do not believe this bill is correct. The
Plan denied your request. The Plan says this cost share was charged based on the services provided and the
Plan contract agreement. We partially overturned the Plans denial. The Plan requested a reopen and
stated that it has been determined that the claim submitted by the provider processed with a payment of
$1,313.96 to the provider with your cost share being $404.81. The provider billed the pharmacy code with
resulted in the $25 administration copayment.
The Plan is correct in this case. 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 administration fee for Medicare Part B drugs
administered during an outpatient service. You had a diagnostic service which required the administration of a
Part B drug. 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 or reduce the cost share charged for outpatient
services and Medicare Part B drugs and administration provided on March 16,2021.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to pay for ambulance response with no transport.
You asked the Plan to pay for ambulance response with no transport. You say that you believe the Plan should
pay this bill. The Plan denied your request. The Plan says Medicare and the Plan do not pay for ambulance
response with no transport. Maximus overturned the Plans denial because the trip report was not included in the
file for verification. The Plan requested a reopen and provided a copy of the trip report.
The Plan is correct in the case. 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 January 8, 2021. The trip report clearly states you refused transport. 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 ambulance response with no transport provided on
January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for any of the dental services provided to on June 8, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says these benefits were exhausted on February 10, 2020 and February 17,
2020. We partially overturned the Plans denial for a lack of claim information in the case file. The Plan
requested a reopen and provided the claim information showing these benefits had been previously exhausted.
The Plan is correct in this case. 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.
The records show the services provided were not available for coverage on June 8, 2021. The record shows that
the Plan previously covered these services on February 10, 2020, and February 17, 2020, less than 3 years ago.
Therefore, we decided that the Plan does not have to pay for the dental services provided to on June 8, 2021.