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

 
We decided that the Plan does not have to reduce the copayment for the two in-network MRIs provided on 
September 16, 2022. 
 
You asked the Plan to reduce the copayment for two MRIs. You say that you want the plan to reduce the 
copayments for your MRIs. 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 $150 
copayment for each in-network outpatient diagnostic Medicare-covered MRI.  
 
You have been asked to pay a $300 copayment for two MRIs ($150 copayment x 2 MRIs = $300). This 
item/service falls within the outpatient diagnostic Medicare-covered MRI 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 reduce the copayment for the two in-network MRIs provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular denture and denture relining (D5751, D5120) 
provided on August 23, 2022. 
 
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 
mandibular denture and denture relining (D5751, D5120) provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 93015 billed for date of service April 21, 
2021. 
 
You asked the Plan to pay for procedure code(s) 93015. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient. 
 
The records indicate that this service was provided to the enrollee while inpatient. Per the Physician Fee 
Schedule, there is a Professional/Technical indicator of 4 for CPT code(s) 93015. Payment for these services 
were included in the facility payment. Based on this information, we decided that Medicare rules for coverage 
of procedure code 93015 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 93015 billed for date of service April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 07, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copaymet. 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 
$120.45 copayment for outpatient surgery/covered surgery in an ambulatory surgical center. 
 
You have been asked to pay a $120.45 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/covered surgery in an ambulatory surgical center 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 surgery provided on September 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy services provided on July 06, 2022. 
 
You asked the Plan to pay for radiation therapy services. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for radiation therapy 
services provided on July 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on November 09, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that this was medically necessary. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on November 09, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast reduction and implant removal provided on 
December 06, 2021. 
 
You asked the Plan to pay for the breast reduction and implant removal. You say that you could not wait to 
have the procedure done. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the breast reduction and 
implant removal provided on December 06, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a unspecified removable prosthodontic procedure and 
complete dentures (D5110, D5899) provided on November 30, 2022. 
 
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 your benefit for the complete dentures has already 
been exhausted. Coverage for the unspecified removable prosthodontic procedure denied correctly as it does 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 31, 2022. Therefore, 
we decided that the Plan does not have to pay for a unspecified removable prosthodontic procedure and 
complete dentures (D5110, D5899) provided on November 30, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from April 2, 
2022 to April 14, 2022. 
 
You asked the Plan to pay for the SNF care. You say that you paid for your service charges in the amount of 
$4,875, and you feel this should be covered in your Medicare plan. The Plan denied your request. The Plan 
says you received an item or service that is never covered by the Plan or Medicare.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did have daily skilled therapy needs that 
required the specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also 
found that you did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from April 2, 2022 to April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an EasyStand stander (E0637) and accessories (E1399). 
 
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you need this for 
movement. You say that the circulation in your legs has gotten bad and your legs get swollen. You also say that 
your doctor is recommending this to help with your circulation and back pain. The Plan denied your request. 
The Plan says the requested DME does not provide a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an EasyStand stander (E0637) and accessories (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service August 2, 
2022. 
 
You asked the Plan to pay for procedure code 99601. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code 99601 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 99601 billed for date of service August 2, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aspiration (20610), provided on June 21, 2021. 
 
You asked the Plan to pay for the aspiration. You say that the services should be covered. The Plan denied your 
request. The Plan says this cost sharing was charged correctly on Claim #820211830540109. Medicare denies a 
claim if it is not received by the plan within twelve months or one calendar year from the date when the 
services were rendered. Claim # 820223430039997 was filed untimely. 
 
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 $50 
specialist copayment for Physician/Practitioner services, including doctor's office visits.  
 
You have been asked to pay a $50 specialist copayment for the aspiration. This item/service falls within the Physician/Practitioner services, including doctor's office visits 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.  
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for aspiration was not filed until December 9, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the aspiration (20610), provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical supplies (D0001) and waive the cost-sharing for the 
deep sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each 
subsequent 15 minute increment (D9223), extraction, erupted tooth or exposed root (D7140 x2) provided on 
August 25, 2022. 
 
 
 You asked the Plan to pay for the surgical supplies (D0001). The Plan says this service is not covered under the 
benefit package. You also asked the Plan to waive the cost-sharing for the deep sedation/general anesthesia  
first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 minute increment (D9223), 
extraction, erupted tooth or exposed root (D7140 x2). The Plan denied your request. The Plan says the cost-
sharing was applied correctly as these services were obtained from an out-of-network provider and the Plan 
only pays up to a certain amount.  
 
DENTAL 
CODE 
DENTIST 
CHARGES 
ALLOWED 
AMOUNT 
PLAN 
PAID 
MEMBER 
RESPONSIBLITY 
D9222 $225 $180 $180 $45 
D9223 $225 $180 $0 $45 
D0001 $50 $0 $0 $50 
D7140 $315 $60 $0 $255 
D7140 $315 $60 $0 $255 
TOTALS $1,130 - $180 $650 
 
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 surgical supplies (D0001) are not 
among those covered under this benefit. The deep sedation/general anesthesia  first 15 minutes (D9222), deep 
sedation/general anesthesia  each subsequent 15 minute increment (D9223), extraction, erupted tooth or 
exposed root (D7140 x2) were provided out-of-network and you are responsible for any amount greater than 
the amount paid by the Plan. Therefore, we decided that the Plan does not have to pay for surgical supplies 
(D0001) provided on August 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to approve an extended stay in the skilled nursing facility. 
 
You asked the Plan to approve a skilled nursing facility stay. You say that the services are necessary as you are 
unable to walk due to surgery. The Plan denied your request. The Plan says your 100-day skilled nursing 
facility stay benefit is exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from June 27, 2022, through 
October 27, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to approve an extended stay in the skilled nursing facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 15, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copaymet. 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 $20 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $20 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 provided on November 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a ceramic crown (D6065) provided on October 4, 2022. 
 
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 ceramic 
crown (D6065) provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spherocylinder, bifocal lens (V2203), progressive lens 
(V2781), anti-reflective coating lens (V2750), and polycarbonate lens (V2784) provided on April 6, 2022. 
 
You asked the Plan to pay for spherocylinder, bifocal lens (V2203), progressive lens (V2781), anti-reflective 
coating lens (V2750), and polycarbonate lens (V2784). You say that these lenses gave you double vision and 
headaches. You also say you cannot even wear them. The Plan denied your request. The Plan says these 
services are 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 covers these services when you purchase basic single vision, lined bifocal, lined trifocal and 
lenticular lenses only. 
 
We looked at the file and the Plan's rules. The Plan rules say that one set of basic single vision, lined bifocal, 
lined trifocal, and lenticular lenses are covered every calendar year. The Plan rules also says that additional 
upgrades, extra charges and /or any customizations are not covered (tinting, coatings and/or special lens 
materials). Based on this information, we decided that the Plan's rules for coverage of spherocylinder, bifocal 
lens (V2203), progressive lens (V2781), anti-reflective coating lens (V2750), and polycarbonate lens (V2784) 
have not been met. Therefore, we decided that the Plan does not have to pay for spherocylinder, bifocal lens 
(V2203), progressive lens (V2781), anti-reflective coating lens (V2750), and polycarbonate lens (V2784) 
provided on April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete barium swallow study (code 74230) and 
radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed 
image(s), when performed; single-contrast (e.g., barium) study (code 74240) provided on September 1, 2022. 
 You asked the Plan to pay for the complete barium swallow study and radiologic examination, upper 
gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; single-
contrast (e.g., barium) study. The Plan denied your request. The Plan says the documentation supports the 
studies represented by the codes were performed at a nursing home (via mobile van/portable x-ray), which are 
denied as an excluded place of service. 
 
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 complete barium swallow study and radiologic examination, upper gastrointestinal tract, 
including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) 
study have not been met. Therefore, we decided that the Plan does not have to pay for a complete barium 
swallow study (code 74230) and radiologic examination, upper gastrointestinal tract, including scout 
abdominal radiograph(s) and delayed image(s), when performed; single-contrast (e.g., barium) study  
(code 74240) provided on September 1, 2022.