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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on June 7, 2022. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this service was on the same day but different times, and you would like to be reimbursed for the services 
rendered. The Plan denied your request. The Plan says the enrollee's claims history indicates the enrollee was in 
an inpatient hospital status on this date of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 is covered under Part A. 
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee was registered as an 
inpatient on the billed date of service. The payment for inter-facility transportation is included in the payment 
to the facility and is the responsibility of the facility to any vendor. Based on this information, we decided that 
Medicare rules for coverage of the non-emergency ambulance transportation and ground mileage have not been 
met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation 
(A0428) and ground mileage (A0425) provided on June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on April 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that this should be covered. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 a telehealth visit provided on April 14, 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 hearing services provided on August 24, 
2022. 
 
You asked the Plan to waive the copayment for hearing 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 $40 
copayment for hearing services.  
 
You have been asked to pay a $40 copayment for hearing services. This item/service falls within the hearing 
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 hearing services provided 
on August 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction of an erupted tooth (D7210) for teeth numbers 
14 and 17, and a bone replacement graft (D7953) provided on August 15, 2022. 
 
You asked the Plan to pay for an extraction of an erupted tooth (D7210) for teeth numbers 14 and 17, and a 
bone replacement graft (D7953). You say that you did not know the Plan only paid for two teeth to be pulled 
per year. You also say that this was an emergency and this procedure had to be done. The Plan denied your 
request. The Plan says there is no coverage for a bone replacement graft (D7953), and they will not cover 
excluded services. The Plan also says that they cover two procedure codes per calendar year for extractions. 
The Plan also says the member already received two extractions on teeth numbers 14 and 17 on March 15, 
2022. 
 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 an extraction of an erupted tooth (D7210) for teeth numbers 14 and 17 was exhausted on 
March 15, 2022. The Plan rules also say that a bone replacement graft (D7953) is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for an extraction of an erupted 
tooth (D7210) for teeth numbers 14 and 17, and a bone replacement graft (D7953) provided on August 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 09, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
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 laboratory services 
provided on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on August 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know that you had a limitation for 
an exam. 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 April 1, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating 
provider on August 31, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for innervating the sacroiliac joint, with image guidance 
provided on June 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for innervating the sacroiliac joint, with image guidance. You say that the services 
provided were medically necessary. The Plan denied your request. The Plan says there is no prior authorization 
or referral on file for the services. 
 
 
 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 innervating the sacroiliac joint, with image 
guidance provided on June 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 22, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the ordering physician is responsible for 
obtaining the authorization. The Plan denied your request. The Plan says the services can be obtained by an in-
network provider and that there is no prior authorization on file for the services rendered. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on August 22, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 4, 2022, billed with 
codes 81226, 81227, 81231, 81328, 81355 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 4, 2022, billed with codes 81226, 81227, 81231, 81328, 81355 and 81401.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hospital outpatient clinic visit provided 
on July 28, 2022. 
 
You asked the Plan to waive the copayment for a hospital outpatient clinic visit. You say that you would like 
the Plan to pay for this. 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 $200 
copayment for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay $114.81 which is less than a $200 copayment for a hospital outpatient clinic visit. 
This item/service falls within the outpatient surgery/in-network/outpatient hospital 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 hospital outpatient clinic visit provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation  per quadrant (D4921 x4) provided on 
July 14, 2022.  
 
You asked the Plan to pay for the gingival irrigation  per quadrant (D4921 x4). You say that you weren't 
aware of the cost of the service and would not have had it done since you may have to have teeth pulled in the 
future. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 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 gingival 
irrigation  per quadrant (D4921 x4) provided on July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests and outpatient hospital 
services provided on June 8, 2022. 
 
You asked the Plan to waive the copayment for laboratory tests and outpatient hospital services. You say that 
you disagree with the copayments. 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 $30 
copayment for outpatient diagnostic tests/lab services and a $90 copayment for outpatient hospital services.  
 
You have been asked to pay a $30 copayment for laboratory tests and a $90 copayment for outpatient hospital 
services. However, you are only being charged $54.18 for outpatient hospital services which is less than the 
required amount. The total amount you are being asked to pay is $84.18 ($30 + $54.18 = $84.18). 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 laboratory tests and outpatient hospital services provided on June 8, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on July 3, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that this 
service was provided on an emergency basis, and you would like this claim to be reprocessed and paid. The 
Plan denied your request. The Plan says you were evaluated and treated for heat exhaustion and low blood 
sugar, but you were not transported anywhere. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 3, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on July 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant /abutment supported removable denture for 
edentulous arch - mandibular (D6111), semi-precision attachment abutment code tooth #'s 22 and 27 (D6052), 
and adjust maxillofacial prosthetic appliance, by report tooth #'s 22 and 27 (D6010). 
 
  You asked the Plan to pre-approve the implant /abutment supported removable denture for edentulous arch - 
mandibular (D6111), semi-precision attachment abutment code tooth #'s 22 and 27 (D6052), adjust 
maxillofacial prosthetic appliance, by report tooth #'s 22 and 27 (D6010). You say that you need the service to 
hold your plaque since you do not have a gum on the bottom of your mouth. The Plan denied your request. The 
Plan says these services are not covered under the benefit package. 
 
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, 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 an 
implant /abutment supported removable denture for edentulous arch - mandibular (D6111), semi-precision 
attachment abutment code tooth #'s 22 and 27 (D6052), adjust maxillofacial prosthetic appliance, by report 
tooth #'s 22 and 27 (D6010). The Plan agreed to pre-approve the cone beam CT capture and interpretation 
(D0367).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroscopy services coded 29827 and 29823 provided on 
March 29, 2022. 
 
You asked the Plan to pay for the arthroscopy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 

 We find that CPT code 29827 and 29823 is not supported in the medical record. Specifically, the operative 
report did not include documentation of a surgical shoulder arthroscopy, with rotator cuff repair; therefore, 
code 29827 cannot be verified. The operative report did not include documentation of a surgical shoulder 
arthroscopy with extensive debridement for 3 or more discrete structures (humeral bone, humeral articular 
cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular 
capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]); 
therefore, code 29823 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the arthroscopy services have not been met. Therefore, we decided that the Plan does not have to 
pay for the arthroscopy services coded 29827 and 29823 provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that we depend upon the facility staff to verify eligibility 
and to obtain the proper authorization from the patients insurance. 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 an office visit provided 
on January 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total application of fluoride varnish (D1206) provided on 
July 28, 2022. 
 
You asked the Plan to pay for a total application of fluoride varnish (D1206). You say that you called the Plan 
and were told that you would be in-network for this policy as long as you are credentialed with Medicare. The 
Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
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 total 
application of fluoride varnish (D1206) provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic imaging (D0330) provided by a participating provider on August 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 a limited oral evaluation (D0140) and a panoramic radiographic imaging (D0330) provided by a 
participating provider on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided from July 28, 2022, to August 12, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. 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 a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs. The total allowed 
amount for the prescription drugs is $7,667.85. The amount you are being asked to pay is $1,533.57 ($7,667.85 
x 20% = $1,533.57). 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 Medicare Part B prescription 
drugs provided from July 28, 2022, to August 12, 2022.