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

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on August 
23, 2022. 
 
You asked the Plan to pay for the dental services. You say that its not your fault that your previous dentist is 
now out-of-network. 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 January 2, 2020. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided 
on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provide on June 22, 
2022. 
 
You asked the Plan to waive the copayment for a 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 $35 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for a 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 a specialist office visit provide on June 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on 
September 20, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital services. 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 $195 
copayment for outpatient hospital services.  
 
You have been asked to pay a $195 copayment for outpatient hospital services. This item/service falls within 
the outpatient hospital 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 
outpatient hospital services provided on September 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography provided on August 11, 2022. 
 You asked the Plan to pay for the fundus photography. You say that you are requesting reconsideration because 
you paid out-of-pocket for the service. The Plan denied your request. The Plan says the service is not a covered 
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 does not cover fundus photography as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the fundus photography is not a covered service. Based 
on this information, we decided that the Plan's rules for coverage of the fundus photography have not been met. 
Therefore, we decided that the Plan does not have to pay for the fundus photography provided on August 11, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 30, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the reports attached support the services provided. The 
Plan denied your request. The Plan says there is no referral or prior authorization on file for the services 
provided. 
 
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 June 30, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient diagnostic tests provided on 
March 9, 2022. 
 
You asked the Plan to waive the copayment for an outpatient diagnostic test. 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 $100 
copayment for outpatient diagnostic tests/Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay a $100 copayment for an outpatient diagnostic test. This item/service falls within 
the outpatient diagnostic tests/Medicare-covered 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 an outpatient diagnostic tests provided on March 9, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network outpatient hospital observation 
provided on July 26, 2022, to July 28, 2022. 
 
You asked the Plan to waive the copayment for in-network outpatient hospital observation. 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 $298 
copayment for in-network outpatient hospital observation.  
 
You have been asked to pay a $298 copayment for in-network outpatient hospital observation. However, you 
are being charged $209.28 which is less than the required amount. This item/service falls within the in-network 
outpatient hospital observation 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 
in-network outpatient hospital observation provided on July 26, 2022, to July 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient diagnostic tests and a specialist 
office visit provided on August 12, 2022. 
 
You asked the Plan to waive the copayment for outpatient diagnostic tests and a 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 $10 
copayment for outpatient diagnostic tests/laboratory tests and a $40 copayment for physician/practitioner 
services/specialist visit.  
 
You have been asked to pay a $10 copayment for outpatient diagnostic tests and a $40 copayment for a 
specialist office visit. You are being asked to pay $3.17 for the diagnostic test which is less than the required amount. The total amount you are being asked pay is $43.17 ($40 + $3.17 = $43.17). 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 diagnostic tests and a specialist office visit provided on August 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a magnetic resonance imaging (MRI) of 
the abdomen and a magnetic resonance imaging (MRI) of the pelvis provided on July 6, 2022. 
 
You asked the Plan to waive the copayments for the MRIs. You say that you were told there would only be 1 
copayment for the procedures. 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 $130 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physician's office or at a free-standing facility. The copayment charged for each MRI was $130. The total 
copayment amount for both MRIs was $260 ($130 copayment + $130 copayment). 
 
  You have been asked to pay a $260 copayment for the MRIs. This item/service 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 copayments for a magnetic resonance imaging (MRI) of the abdomen and a magnetic resonance imaging 
(MRI) of the pelvis provided on July 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for skilled nursing facility (SNF) provided on 
May 1, 2022, to May 20, 2022. 
 
You asked the Plan to waive the cost share for SNF. 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 the enrollee will pay a 
$7,550 for maximum out-of- pocket amount per your plan under Section 1.2 What is the most you will pay for 
covered medical services? You must also pay a $0 copayment per day for days 1-20 and $180 copayment per 
day for days 20-44 for skilled nursing facility (SNF) care.  
 
 You have been asked to pay a $0 copayment per day for days 1-20 and $180 copayment per day for days 20-
44. The total allowed amount is $3,420 ($180 x 19 days = $3,420). However, you are only being charged 
$3,139.79 which is your remaining balance of the out-of-pocket maximum. 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 cost share for skilled nursing facility (SNF) provided on May 1, 2022, to May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 office visit provided on January 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for nail debridement (11720) billed for date of service July 7, 2022.

You asked the Plan to pay for nail debridement (11720). You say that the medical records support the services
billed and the claim should be reprocessed. The Plan denied your request. The Plan says that procedure code
11720 is mutually exclusive to procedure code 11056 and the use of a modifier is not supported.
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 11720
is a column II code to column I code 11056; however, 11720 was billed with a modifier.

We asked our coder 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 nail debridement (11720). Our reviewer says that the
documentation supports the use of procedure code 11720 with modifier 59. Our reviewer found there was
debridement on two toenails as well as removal of a heal callus. These procedures were distinct and separate.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nail debridement (11720) have been met. Therefore, we decided that the Plan
has to pay for nail debridement (11720) billed for date of service July 7, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 18, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollees network primary care physician (PCP) or plan must give the enrollee 
approval in advance before they can use providers not in the plan's network. This is called giving them a 
"referral." 
 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 office visit provided on July 18, 2022, by an out-
of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown replacement (D2750) 
 
You asked the Plan to pre-approve the dental services. 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 pre-approve a 
crown replacement (D2750)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the request is not medically necessary, when the enrollee 
is ready to leave the hospital, they can safely receive this care in another setting, such as a Skilled Nursing 
Facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH facility.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D6065) provided on 
 
You asked the Plan to pay for the dental services. 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 crown 
(D6065) provided on
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 1, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 related to end-stage renal disease (ESRD) provided on July 1, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implants (D6066) and a lower overdenture (D5866) for 
tooth #21, #23, #26, #28. 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary. The Plan 
denied your request. The Plan says the implants are not a covered service and documentation does not show 
existing supporting implants to support the overdenture. 
 
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 pre-approve the dental services. Our reviewer says 
that the lower overdenture is not medically necessary, and the Plans supplemental dental plan excludes 
implants. Our physician reviewer found that in this case, the record indicates that the enrollee only has 2 lower 
teeth and that this is insufficient to support a mandibular overdenture. Therefore, the planned mandibular 
overdenture would have insufficient support and is therefore not medically necessary as defined by Medicare 
rules. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare 
rules, of the requested service. The elements of the coverage criteria are not satisfied. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve implants (D6066) and a lower overdenture (D5866) for tooth #21, #23, #26, #28.