Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99309 provided on September 2, 2021. 
 
You asked the Plan to pay for procedure code 99309. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for procedure code 99309 based on Medicare criteria. The Plan denied services stating that the place 
of service (POS) reported on the claim at issue does not correspond to the facility bill. However, the Plan did 
not provide any facility bill to verify if this is accurate. Therefore, we decided that the Plan has to pay for 
procedure code 99309 provided on September 2, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the ballet classes purchased on January 1, 
2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 The Plans rules for coverage of gym benefits have not been met because ballet classes are not a covered 
benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the ballet classes 
purchased on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on November 21, 2022. 
 
You asked the Plan to pay for the 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 May 12, 2022. Therefore, 
we decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), and panoramic radiographic image (D0330) provided on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a detailed and extensive oral evaluation (D0160). 
 
You asked the Plan to pay for a detailed and extensive oral evaluation. You say that this exam was medically 
necessary. The Plan denied your request. The Plan says dental related services are excluded from coverage. 
 
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 detailed 
and extensive oral evaluation (D0160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the 
panoramic radiographic image (D0330) provided on December 15, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided was exhausted on date of service August 18, 2022. Specifically, 
the Plan contract states that a comprehensive oral evaluation is covered once every three calendar years and a 
panoramic radiographic image is covered once every five calendar years.  You previously received these services on August 18, 2022, which were paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for these services. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation (D0150) and the panoramic radiographic image (D0330) provided 
on December 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 24, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 24, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 27, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 27, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the member had multiple exams done on 
this date of service. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service August 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the special supplemental benefit for the chronically ill 
(SSBCI) benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you have multiple medical issues. The 
Plan denied your request. The Plan says you do not qualify for these benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the special supplemental benefit for the chronically ill (SSBCI) benefits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for antigen therapy services and immunotherapy 
injections provided on September 12, 2022, to October 3, 2022. 
 
You asked the Plan to waive the cost share for antigen therapy services and injections. You say that you dont 
understand why you are being charged for injections and office visits when you never see the doctor. 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 $25 
copayment for physician specialist services.  
 
 You have been asked to pay a $11.03 copayment for each antigen therapy services because the allowed amount 
for this service is less than the $25 copayment ($11.03 copayment x 3 services = $33.09). This item/service 
falls within the physician specialist services benefit category. You have been asked to pay a $1.79 coinsurance 
for each injection ($8.95 allowed amount x 20% coinsurance = $1.79 applied coinsurance). For 3 dates of 
service, you have been charged a total of $5.37 coinsurance ($1.79 x 3 dates of service = $5.37). This 
item/service falls within the physician specialist services benefit category. You have been asked to pay a total 
of $38.46 ($33.09 copay + 5.37 coinsurance = $38.46). 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 
antigen therapy services and immunotherapy injections provided on September 12, 2022, to October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on November 8, 
2022. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you believe the office should be paid for this 
x-ray. 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 this same date of service November 8, 
2022. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on 
November 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for home health agency care provided on 
February 07, 2022, to March 07, 2022. 
 
You asked the Plan to waive the coinsurance for home health agency care. You say that you disagree with the 
coinsurance. 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 20% 
coinsurance for home health agency care. 
 
You have been asked to pay 20% coinsurance for home health agency care. This item/service falls within the 
home health agency care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for home 
health agency care provided on February 07, 2022, to March 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for a comprehensive oral evaluation (D0150), 
prophylaxis - adult (D1110), bitewings - four radiographic images (D0274), intraoral - periapical first 
radiographic image (D0220),  and intraoral - periapical each additional radiographic image (D0230) provided 
on August 25, 2022. 
 
You asked the Plan to waive the cost sharing for codes D0150, D1110, D0274, D0220 and D0230. You say that 
it appears that you may have used an out-of-network dental provider. You also say that the Evidence of 
Coverage and Explanation of Benefits for Dental Care state that routine care is covered both in and out-of-
network. The Plan denied your request. The Plan says you are responsible for the full amount by which the 
actual charges of an OON dentist exceed the allowable charge. 
 
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 OON provider billed $349.65 for the dental codes billed, and the Plan covered each of those dental codes 
and paid for them at their allowed amounts totaling $165. The difference between the OON providers billed 
amounts and the Plans allowed amounts was $184.65 ($349.65 - $165 = $184.65). The Plan contract says that 
members will be responsible for the full amount by which the actual charges from an OON dentist exceed the 
allowable charge. Therefore, we decided that the Plan does not have to waive the cost sharing for a 
comprehensive oral evaluation (D0150), prophylaxis - adult (D1110), bitewings - four radiographic images 
(D0274), intraoral - periapical first radiographic image (D0220),  and intraoral - periapical each additional 
radiographic image (D0230) provided on August 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on October 11, 2022. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a disposable drug delivery system (A4305) provided from 
April 8, 2021, to April 14, 2021. 
 
You asked the Plan to pay for a disposable drug delivery system. The Plan denied your request. The Plan says 
disposable drug delivery systems, including elastomeric infusion pumps (A4305) are non-covered devices 
because they do not meet the Medicare definition of durable medical equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including 
elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the 
Medicare definition of durable medical equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a disposable drug delivery system have not been met. Therefore, we decided that the Plan does not 
have to pay for a disposable drug delivery system (A4305) provided from April 8, 2021, to April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on November 7, 
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 core 
buildup services (D2950) provided on November 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on July 25, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the patient had two transports on the same date of service, July 25, 2022, for a vascular procedure. The Plan 
denied your request. The Plan says based on the information received the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that this includes transportation  including 
transportation by ambulance  to and from another hospital or freestanding facility to receive specialized 
diagnostic or therapeutic services not available at the facility where the patient is an inpatient.  
 
The enrollee was a hospital inpatient at the time of service and was transported to a separate facility for testing 
which means this ambulance service is included in the inpatient payment and is not separately paid by 
Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance service, basic life support, non-emergency transport have not been met. Therefore, 
we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental fillings (D2394, D2393, D2331) provided on October 
21, 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 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 September 16, 2022. 
Therefore, we decided that the Plan does not have to pay for dental fillings (D2394, D2393, D2331) provided 
on October 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a chronic care management office visit 
provided on September 30, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that the provider failed to 
disclose important information about a program at no cost to you that you are unable to take and now you are 
being charged with a specialist office visit. 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 $25 
copayment per visit to a specialist.  
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner 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 a 
chronic care management office visit provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan and pulp 
vitality tests (D0364, D0460) provided on October 31, 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 cone 
beam computed tomography (CT) scan and pulp vitality tests (D0364, D0460) provided on October 31, 2022.