Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213 billed for date of service July 6, 2021. 
 
You asked the Plan to pay for procedure code 99213. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 99213 is bundled into 
payment for code 90834. 
 
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 99213 
is a column II code to column I code 90834 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99213 billed for date of service July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve post and core in addition to a crown (D2954). a crown 
(D2750), and endodontic therapy (D3310/D3320). 
 
You asked the Plan to pre-approve the dental services. You say that you were told that this dental work is 
needed. The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve post and 
core in addition to a crown (D2954). a crown (D2750), and endodontic therapy (D3310/D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and related services provided on October 14, 
2022. 
 
You asked the Plan to pay for a home visit and related services. You say that you were not aware that this 
provider was out-of-network. 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 a home visit and related 
services provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid ear mold (V5264) provided on October 4, 
2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for the 
item provided in this case. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of this item have not been met. Specifically, the Plan contract states that coverage is provided for 
hearing aids every 24 months in the amount of $1,700. The Plan previously issued payment in the amount of 
$1,700 for hearing aids purchased on August 5, 2022. Therefore, you have exhausted the allowable benefit for 
this item. Therefore, we decided that the Plan does not have to pay for the hearing aid ear mold (V5264) 
provided on October 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and the intraoral 
radiographic image (D0230) provided on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that your share should be reimbursed because your 
crown came off and the treatment was medically necessary. The Plan denied your request. The Plan says your 
benefit for the intraoral radiographic image has already been exhausted. Also, the denial of payment for the 
limited oral evaluation is correct because it is not covered by the 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on December 14, 2022; therefore, your 
benefit for the intraoral radiographic image was exhausted on the date of service of December 14, 2022. The 
limited oral evaluation is not covered under the Plans dental benefit. Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation (D0140) and the intraoral radiographic image (D0230) provided on 
December 14, 2022.
Appeal type: Testing
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 December 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the services were medically 
necessary. 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 
December 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652), segmental pneumatic 
appliance for use with pneumatic compressor, full leg (E0667), and segmental pneumatic appliance for use 
with pneumatic compressor, trunk (E0656). 
 
You asked the Plan to pre-approve a pneumatic compressor, a full leg segmental pneumatic appliance, and 
segmental pneumatic appliance for the trunk. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 The Plan follows Medicare rules. Medicare rules say that a segmented, calibrated gradient pneumatic 
compression device (HCPCS code E0652) is only covered when the individual has unique characteristics 
which prevent them from receiving adequate satisfactory pneumatic compression treatment using a 
nonsegmented device along with a segmented appliance or compression device without manual control of the 
pressure in each chamber. 
 
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 a pneumatic compressor, a full leg 
segmental pneumatic appliance, and segmental pneumatic appliance for the trunk. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that the segmental pneumatic compression device with calibrated gradient pressure 
(E0652) at issue in this case meets all Medicare criteria for medically reasonable and necessary for you. 
Provided records in this case do not document at least four weeks of regular, daily, multiple-hour home usage 
of a basic pump after careful, in-person fitting, training and supervision by a technician who is skilled in and 
who regularly and successfully uses the appliance provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a pneumatic compressor, a full leg segmental pneumatic appliance, and 
segmental pneumatic appliance for the trunk have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compressor (E0652), segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667), and segmental pneumatic appliance for use with pneumatic compressor, trunk 
(E0656).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation  new or established patient 
(D0150) and panoramic radiographic image (D0330) provided on November 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are requesting your insurance to cover the 
services you were billed for. 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. This benefit includes the 
requested comprehensive oral evaluation  new or established patient (D0150) and panoramic radiographic 
image (D0330) but each is limited to once every three plan years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0150 and D0330 on October 13, 2021. Therefore, your benefit was exhausted as 
of October 13, 2021. Therefore, we decided that the Plan does not have to pay for comprehensive oral 
evaluation  new or established patient (D0150) and panoramic radiographic image (D0330) provided on 
November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza vaccine and the administration provided on 
December 15, 2022. 
 
You asked the Plan to pay for the influenza vaccine and the administration. You say that these services were 
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 the influenza vaccine 
and the administration provided on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 06, 2022. 
 
You asked the Plan to pay for office visit. 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 office visit provided on 
December 06, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the heel x-rays provided on November 21, 2022. 
 
You asked the Plan to pay for the heel x-rays. You say that the records provided support medical necessity. 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 heel x-rays provided 
on November 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation - new/established patient 
(D0150) and intraoral - complete series of radiographic images including bitewing (D0210) provided on 
November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that without new x-rays your provider would not 
have been able to diagnose the problem you were having. You say that your insurance should cover this. 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. This benefit includes the 
requested comprehensive oral evaluation - new/established patient (D0150) but is limited to one procedure 
code every three calendar years and intraoral - complete series of radiographic images including bitewing 
(D0210) but is limited to one procedure code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D0150 on May 20, 2019, and October 14, 2022, and received covered D0210 on 
October 14, 2022. Therefore, these benefits were exhausted as of October 14, 2022. Therefore, we decided that 
the Plan does not have to pay for comprehensive oral evaluation - new/established patient (D0150) and 
intraoral - complete series of radiographic images including bitewing (D0210) provided on November 28, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing - four or more teeth per 
quadrant (D4341) x2 provided on November 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of frequency limitations. 
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. This benefit includes the 
requested periodontal scaling and root planing - four or more teeth per quadrant (D4341) but is limited to one 
procedure code per quadrant every three calendar years. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered D4341 on October 7, 2020. Therefore, the benefit was exhausted on October 7, 
2020. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing - four 
or more teeth per quadrant (D4341) x2 provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
20, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 
70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 20, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for imaging services provided on December 14, 2022, billed with code 
71045-26. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the claim was billed with an invalid place of 
service. 
 
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. Though it is true that the TC cannot be paid in the facility setting, the 
documentation shows that only the professional component was billed Therefore, we decided that the Plan has 
to pay for imaging services provided on December 14, 2022, billed with code 71045-26.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve the routine transportation services.  The Plan denied your request. The Plan 
says that the information provided shows that you are not treated for diabetes or congestive heart failure. You 
do not meet the medical necessity criteria required for approval of the transportation services requested.  
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when You do not have both qualifying diagnoses.  
 
We looked at your request, the records in the case file, and the rules. The record shows you are not being 
treated for diabetes or congestive heart failure. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve routine transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99213, J3301, 17110, 29530, and 20610 
provided on November 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for procedure codes 99213, J3301, 17110, 29530, and 20610 provided by an OON 
provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your 
request. The Plan says procedure code 29530 is a column II code to column I code 20610 and is not separately 
payable. The Plan further states the provided services were neither emergent nor urgent and prior authorization 
was not obtained to provide out-of-network care. 
 
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. Medicare rules also say that providers must report services 
correctly. 
 
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. 
Additionally, we have confirmed that code 29530 is a column II code to column I code 20610 and has not been 
billed with an appropriate modifier to bypass the edit. Therefore, we decided that the Plan does not have to pay 
for procedure codes 99213, J3301, 17110, 29530, and 20610 provided on November 17, 2022, by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the positron emission tomography scan 
provided on October 21, 2022. 
 
You asked the Plan to waive the copayment for the positron emission tomography scan. You say that you 
cannot afford 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 $160 
copayment for in-network outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $160 copayment for the positron emission tomography scan. This item/service falls within the in-network outpatient diagnostic tests and therapeutic services and supplies benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the positron emission tomography scan provided on October 
21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 30, 2022. 
 
You asked the Plan to pay for an office visit. You say that you rendered the services in good faith. 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 December 30, 2022.