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

 
We decided that the Plan does not have to pay for a mandibular bone graft provided on December 21, 2021. 
 
You asked the Plan to pay for bone graft. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service is not covered by the Plan's 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 bone graft provided on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic comprehensive preventive medicine 
reevaluation and management (99397). 
 
You asked the Plan to pre-approve a periodic comprehensive preventive medicine reevaluation and 
management. You say that the requested service is a necessity for the enrollee's care. The Plan denied your 
request. The Plan says rules for coverage have not been met. 
 
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 99397 has a Status Indicator of N on the Physician Fee Schedule. This means that CPT 
code 99397 is a non-covered service. Based on this information, we decided that Medicare rules for coverage 
of a periodic comprehensive preventive medicine reevaluation and management have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a periodic comprehensive preventive medicine 
reevaluation and management (99397).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010), prefabricated abutments 
(D6056), modification of removable prosthesis following implant surgery (D5875) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve dental services. You say that you are aware of the wait for dentures, but you 
urgently need a replacement and feel these should be covered due to necessity. The Plan denied your request. 
The Plan says while the denture is a covered service, you previously received a complete lower denture on 
February 18, 2020, which was covered at that time. Your benefit covers one complete lower denture in a five-
year period. The implants, abutments and modification of prosthesis are not covered services under your dental 
benefit. 
 
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 or are requested in a frequency that exceeds what is covered by this 
benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants (D6010), 
prefabricated abutments (D6056), modification of removable prosthesis following implant surgery (D5875) and 
a complete lower denture (D5120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you do not drive or have any means 
of transportation. You also say that you would like additional rides approved so you can see your doctors. The 
Plan denied your request. The Plan says your benefit plan allows for up to 10 one-way trips per plan year for 
routine non-emergency visits to plan approved locations such as doctor's appointments. The Plan also says that 
extra one-way trips cannot be approved. 
 
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 a maximum of up to 10 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided records to support 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 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 March 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy with polyp removal 
provided on March 14, 2022. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that your doctor required you have this 
testing and that you do not feel you should be responsible for the copayment. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $250 
copayment for in-network outpatient surgical services at an ambulatory surgical center.  
 
You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 colonoscopy with polyp removal provided on 
March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation (T2003). 
 
You asked the Plan to pre-approve the non-emergency transportation. You say that you would like to appeal 
the denial for the round-trip benefit. The Plan denied your request. The Plan says this benefit is for members 
who are diagnosed with both diabetes and congestive heart failure. The Plan also says that you have pre-
diabetes, but not diabetes, and you do not have CHF. 
 
  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 are diagnosed with both diabetes and congestive heart 
failure (CHF).  
 
We looked at your request, the records in the case file, and the rules. 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 non-emergency transportation (T2003).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on January 11, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
 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 skilled nursing facility services provided on 
January 11, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided on January 14, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for hospital services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services were not urgent or emergent. 
 
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 hospital services provided on January 14, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the infrared therapy (97026), office visits 
(99213, 99214), electrical stimulation (97032), and the durable medical equipment (E1399) provided from 
October 28, 2021, through March 3, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 
 
 The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to issue reimbursement for the infrared therapy (97026), office visits (99213, 
99214), electrical stimulation (97032), and the durable medical equipment (E1399) provided from October 28, 
2021, through March 3, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 26, 2022. 
  You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service. You say that the attached reports support the level of service, and the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit. 
 
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 the CT scan (70450) provided on February 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray provided on February 17, 2022. 
 
You asked the Plan to waive the copayment for the x-ray. You say that you were under the impression the x-ray 
copayment was only $20. The Plan denied your request. The Plan says the copayment was applied 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 
copay when X-rays are performed in an Outpatient Hospital Facility.  
 
 
 
 
 
 
 
 
 You have been asked to pay the allowed amount of $82.50 for the x-ray rather than the standard $150 
copayment. The x-ray falls within the Outpatient diagnostic tests and therapeutic services and supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided on February 
17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for dates of service October 6, 
2021, and October 8, 2021. 
 
You asked the Plan to pay for procedure code 97110. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says code 97110 is not the appropriate code for the services 
provided. 
 
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, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that 
CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were 
performed in the home setting and there is a more appropriate code for these services. Based on this 
information, we decided that Medicare rules for coverage of procedure code 97110 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 97110 billed for dates of service 
October 6, 2021, and October 8, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit on February 3, 2022, 
through February 4, 2022. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the hospital wanted to keep 
you, but they did not have any space. You say that you did not wish to wait for a room and requested to leave. 
The Plan denied your request. The Plan says coinsurance is correct. 
 
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 $65 
copayment for each emergency room visit.  
 
You have been asked to pay $65 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency 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 copayment for emergency 
room visit on February 3, 2022, through February 4, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve skilled nursing facility (SNF) care.. You say that the enrollee has shortness 
of breath.  The Plan denied your request. The Plan says admission is not medically necessary. 
 
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 pre-approve SNF care. Our physician reviewer 
found the enrollee does not qualify for SNF coverage. The enrollee does not have daily skilled nursing needs 
that require the specialized skill knowledge, and judgement of a skilled professional nurse. The enrollee does 
not have daily skilled therapy needs that require the specialized skill, knowledge, and judgement of a skilled 
professional therapist. The enrollee is consistently ambulating more than 100 feet and tending to activities of 
daily living with minimal supervision. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial 
and intermittent, can, as a practical matter, be provided at a lower level of care (ex. home, assisted living, long-
term care). The enrollee does 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 SNF care. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lanreotide injection (J1930) provided on 
November 12, 2021. 
 
You asked the Plan to waive the coinsurance for the lanreotide injection. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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, and the administration of them.  
 
  
You have been asked to pay a 20% coinsurance for the lanreotide injection (allowed is $6,661.20 x 20% = 
$1,332.24). Lanreotide injections fall within the Medicare Part B prescription drugs 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 a lanreotide injection (J1930) provided on November 12, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) 
provided on November 17, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like this 
claim reprocessed for medical necessity. The Plan denied your request. The Plan says this service is non-
covered by Medicare as it is unlikely to impact therapeutic decision-making in the clinical management of the 
patient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the targeted genomic sequence 
analysis panel (81455) provided on November 17, 2021, have been met. In this case, no medical documentation 
was provided from the enrollees provider to support the request for the ordered genetic testing. Therefore, we 
decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (81455) provided 
on November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
November 10, 2021, to November 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that both stays should be treated as 
one and you should only be responsible for one copayment. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $345 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission.  
 
The file shows that you were transferred to a different facility for inpatient care from November 10, 2021, to 
November 24, 2021. This transfer is considered a new admission. Therefore, you have been asked to pay $345 
per day for the first 5 days of inpatient care. The total for your stay is $1,725 ($345 copayment x 5 days = 
$1,725). The inpatient care falls within the Inpatient Hospital 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 copayment for inpatient hospital care provided from 
November 10, 2021, to November 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve Magnetic Resonance Imaging (MRI). You say that you need to use the 
stand-up MRI. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
Magnetic Resonance Imaging (MRI) to be provided by an out-of-network (OON) provider.