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

 
We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided on 
February 22, 2022. 
 
You asked the Plan to pay for the pre-diagnostic test. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says an adjunctive pre-diagnostic test (D0431) is 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 an 
adjunctive pre-diagnostic test (D0431) provided on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed on January 25, 2022. 
 
You asked the Plan to pay for procedure code 99100. The Plan denied your request. The Plan says procedure 
codes 01402 and 64447 have been overturned. The Plan also says procedure code 99100 remains denied as 
bundled services are not eligible for separate payment. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99100 billed on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you didn't know the provider was no longer 
participating with your insurance. The Plan denied your request. The Plan says the provider is out-of-network, 
and it was determined these services can be received in-network. 
 
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 an office visit provided on February 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on March 3, 2022.
You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the copayment applied is correct. The provider has said that they are going to reimburse the member $315.72.
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 $195 copayment for a computerized tomography (CT) scan. The copayment of $134.58 you are being charged is correct since the amount due is under the normal $195 copayment You have been asked to pay a $195 copayment for a computerized tomography (CT) scan. A computerized tomography (CT) scan falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for a computerized tomography (CT) scan on March 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (filling) for tooth number 24 
provided on February 28, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy. 
 
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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based 
composite (filling) for tooth number 24 provided on February 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus Kit w/Device and Accu-Chek 
Aviva Plus In Vitro Strips (E0607, A4253). 
 
You asked the Plan to pre-approve diabetic supplies. You say that you currently use the requested items, and 
you test twice per day using 45 strips per month. The Plan denied your request. The Plan says they were not 
able to determine if you meet criteria. The Plan tried to reach your prescriber for this information, and they did 
not receive a response. The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day. The EOC confirms that you must try and fail preferred blood 
glucose testing products that are covered by your Plan. You may not have to try these products if your provider 
provides information that shows why the preferred products are not right for you. The documentation also 
indicates that the Plan reached out to the provider on 7/12/2022, 7/13/2022 and 7/14/2022 to confirm if you met 
criteria for the requested items; and did not receive a response. Based on this information, we decided that 
Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Accu-Chek Aviva Plus Kit w/Device and Accu-Chek Aviva Plus In Vitro Strips 
(E0607, A4253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) and fluoride treatment 
(D1206) provided on February 8, 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 periodontal maintenance (D4910) and fluoride treatment (D1206) 
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 
periodontal maintenance (D4910) and fluoride treatment (D1206) provided on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening services 
provided on January 27, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening services. You say that this testing 
service should be reprocessed and approved for payment based on medical necessity. The Plan denied your 
request. The Plan says this testing is not covered by Medicare or the Plan. 
 
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 pay for the cardiac risk assessment genetic screening 
services. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. 
 Our physician reviewer found the provided test is described as a genetic based cardiovascular risk factor 
screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It 
assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with 
increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this patient clinical 
management. In summary, the requested testing is not considered reasonable or medically necessary. 
 
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 cardiac risk assessment genetic screening services have not been met. 
Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic screening 
services provided on January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on February 2, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you shouldn't have to pay this 
large of an amount. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $300 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
 
 
 You have been asked to pay $283.18 which is less than the standard $300 copayment for outpatient surgery. 
Outpatient surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, intraoral periapical x-rays, 
bitewing x-rays, and periodontal maintenance provided on January 5, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the dental services. 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 the periodic oral evaluation, intraoral periapical x-rays, bitewing x-rays, and periodontal maintenance 
provided on January 5, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (J7321) and drain/inject of large joint (20610) on June 30, 2021.

You asked the Plan to waive the copayment for an injection (J7321) and drain/inject of large joint (20610). You say that you would like to appeal the cost share. The Plan denied your request. The Plan says the copayment applied is correct.

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 $195 copayment for an injection (J7321) and drain/inject of large joint (20610). The member was charged the eligible amount of $27 for each the left and right side, so the total copayment is $54.  The member has a responsibility of $54 because it is less than the allowed amount of $195.

You have been asked to pay a $195 copayment for an injection (J7321) and drain/inject of large joint (20610). An injection (J7321) and drain/inject of large joint (20610) falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 injection (J7321) and drain/inject of large joint (20610) on June 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on January 26, 2022. 
 
You asked the Plan to pay for the testing services. You say that you were not given any indication that it would 
not be covered. The Plan denied your request. The Plan says that coverage is excluded for services considered 
not reasonable and necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the testing services by a contract provider. The file does not show that the Plan provided 
notice that the testing services would not be covered. Under Medicare rules, this means the testing services is 
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab testing services 
provided on January 26, 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 the post and core in addition to crown on tooth #29 (D2952) 
provided on December 15, 2021. 
 
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 post and core in addition to crown (D2952) is 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 post 
and core in addition to crown on tooth #29 (D2952) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical removal of an erupted tooth (code D7210) 
and panoramic film (code D0330) provided on February 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe you should be reimbursed the 
full amount. 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 Plan's 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 annual benefit applied $449 on January 8, 2022. The remaining amount of your annual benefit 
($301) was applied to these services provided on February 14, 2022. Your total annual benefit has now been 
exhausted. Therefore, we decided that the Plan does not have to pay more for the surgical removal of an 
erupted tooth (code D7210) and panoramic film (code D0330) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing - one to three teeth 
per quadrant (D4342) provided March 23, 2022. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you cannot afford this 
service. The Plan denied your request. The Plan says this service is 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 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 
periodontal scaling and root planing - one to three teeth per quadrant (D4342) provided March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says separate payment is not made for this 
claim per Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140), panoramic x-rays 
(D0330), nitrous oxide (D9230), extraction of tooth #20 (D7210), extraction of tooth #5 and 19 (D7140), and 
removal of residual roots on tooth #4 (D7250) provided on April 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you do not understand why these services 
were not covered. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plan's 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
payment. 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 pay more for a limited oral evaluation (D0140), 
panoramic x-rays (D0330), nitrous oxide (D9230), extraction of tooth #20 (D7210), extraction of tooth #5 and 
19 (D7140), and removal of residual roots on tooth #4 (D7250) provided on April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, expandable controller, and harness for upgrade to expandable 
controller. 
 
You asked the Plan to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors, expandable controller, and harness for upgrade to expandable controller. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet 
criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that your caregivers will be operating the 
power wheelchair. Your caregivers can control the power options using their own switches which are included 
in the allowance of the approved power options. Based on this information, we decided that Medicare rules for 
coverage of electronic connection between wheelchair controller and two or more power seating system 
motors, expandable controller, and harness for upgrade to expandable controller have not been met. Therefore, 
we decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors, expandable controller, and harness for upgrade to expandable 
controller.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
23, 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 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 December 15, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 23, 2022.