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

 
We decided that the Plan does not have to pay for the lab testing services provided on July 30, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a lung cancer panel was provided. The testing panel was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure.  
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telomerase reverse transcriptase (TERT) testing provided on 
August 23, 2021, billed with code 81345. 
 
You asked the Plan to pay for the TERT testing as billed. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says code 81345 was not billed with a required modifier. 
 
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 81345 
is a column II code to column I code 0089U. 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 telomerase reverse transcriptase (TERT) testing provided on 
August 23, 2021, billed with code 81345.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the spinal injection provided by a network 
facility on November 29, 2021. 
 
You asked the Plan to reduce the copayment for the spinal injection. You say that previously, you have paid a 
$25 copayment for the injection. The Plan denied your request. The Plan says you have been asked to pay 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 $150 
copayment per day for other outpatient procedures and services, including, but not limited to, diagnostic and 
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical 
center.  
 
You have been asked to pay a $150 copayment for the spinal injection. The spinal injection falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. The record shows you were billed by the outpatient hospital facility.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for the spinal injection provided by a network facility on 
November 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services provided on October 25, 2021. 
  You asked the Plan to pay for occupational therapy services. You say that the records indicate these are valid 
codes and medical records support the services billed. You say that the attached medical records should be 
reviewed, and the claims reconsidered for reimbursement. The Plan denied your request. The Plan says the 
code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services billed as services incident to a 
physician/non-physician practitioners service must meet all incident requirements. Medicare rules also say that 
the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) 
service, because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the records do not indicate if the 
rendering provider was an occupational therapist or an OTA. A nurse practitioner is not able to bill for the 
services of an OTA because the nurse practitioner is not a therapist. There is no evidence that the nurse 
practitioner was on the premises to be able to bill for OT services. Additionally, the record does not include the 
rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the 
Plan does not have to pay for occupational therapy services provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup for tooth #18 (D2950), and a crown for 
tooth #18 (D6740) for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is needed to restore tooth anatomy and 
protect the tooth due to placement of restoration. The Plan denied your request. The Plan says the furcation 
involvement does not meet medical criteria for a crown due to the poor prognosis of tooth #18. 
 
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. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 the dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the 
documentation provided does not meet the criteria for coverage for core buildup and crown restoration for 
tooth #18. More information is required regarding the extent of the fracture to determine the prognosis of tooth 
#18 retention. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup for tooth #18 (D2950), and a crown for tooth #18 (D6740) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided from 
February 17, 2022 to February 18, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went to the ER for 
sores in your mouth and throat. You say that you were transferred to a medical center because there was no 
ENT available. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $65 
copayment for emergency services at an in-network emergency room.  
 
  
You have been asked to pay a $65 copayment for an 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 an 
emergency room visit provided from February 17, 2022 to February 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 5 units of prostate biopsy services (G0416) provided on 
September 27, 2021.  
You asked the Plan to pay for 5 units of prostate biopsy services. You say that you would like this claim 
reprocessed and approved for payment based on the medical records. The Plan denied your request. The Plan 
says the number of units billed have exceed the Medicare Unlikely Edit value. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code G0416 is 1. The MAI value for this code is 2. You billed 6 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 5 units of 
prostate biopsy services have not been met. Therefore, we decided that the Plan does not have to pay for 5 units 
of prostate biopsy services (G0416) provided on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the copayment for the computerized tomography (CT) scan 
provided on December 2, 2021. 
 
You asked the Plan to pay for the copayment for the CT scan. You say that you would like the Plan to pay for 
CT scan. The Plan denied your request. The Plan says the proper copayment was applied for the service that 
was rendered. 
 
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 $110 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physicians office or at a free-standing facility. The total amount allowed was $89.42 which is less than the 
copayment amount of $110. Therefore, the $89.42 was charged as the copayment amount. You have been asked to pay a $89.42 copayment for the CT scan. The CT scan 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 pay for 
the copayment for the computerized tomography (CT) scan provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Vision Care services provided on December 6, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Vision Care services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the member has no out of network benefits and 
the provider is out-of-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 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 Vision Care services provided on December 6, 
2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on December 13, 
2021, by an OON provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like your claim 
processed accordingly. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was 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 the outpatient hospital services provided on 
December 13, 2021, by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 additional physical therapy home health visits. 
You asked the Plan to pre-approve additional home health services. You say that this home health care is 
medically necessary. The Plan denied your request. The Plan says these additional home health visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health services. Our 
reviewer says that the requested additional home health physical therapy visits are not medically reasonable 
and necessary. Our physician reviewer found that based on the documentation provided, the enrollee does not 
have documented, ongoing, home health physical therapy needs. The enrollee is functioning at a level 
commiserate with a lower level of care (i.e. home exercise program, outpatient therapy). The enrollee has 
available caregivers.  As such, the requested, ongoing, home health physical therapy services are not medically 
necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 14 additional physical therapy home health visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Laboratory services provided on January 31, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for Laboratory 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 authorization 
is required prior to an out-of-network visit. 
 
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 January 31, 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 copayments for debridement services provided by a 
network facility from August 13, 2021, to September 22, 2021. 
 
You asked the Plan to waive the copayments for the debridement services. You say that you were unaware you 
had a copayment, and you would have gone elsewhere for the services. You say you are on a fixed income and 
do not qualify for Medicaid. The Plan denied your request. The Plan says you have been asked to pay 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 $325 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $325 copayment for the debridement services on each date of service. ($325 x 5 
dates of service = $1,625). The debridement services fall within the Outpatient Surgery and Other Medical 
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 copayments for debridement services provided by a network facility from 
August 13, 2021, to September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on January 6, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the podiatry services. You say that it was medically necessary to treat the 
enrollee and you would like to appeal the denied claim. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was 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 the podiatry services provided on January 6, 2022, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) provided by a participating provider on 
January 10, 2022. 
 
You asked the Plan to pay for bitewings. You say that you went to get a second opinion. You say that the first 
doctor was going to charge you too much. The Plan denied your request. The Plan says the benefit limit for 
D0274 has already been met and exhausted. 
 
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. The Plan covers bitewings 
once per plan year.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0274 was previously provided. 
Based on this information, we decided that the Plan's rules for coverage of bitewings have not been met. 
Therefore, we decided that the Plan does not have to pay for bitewings (D0274) provided by a participating 
provider on January 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the amalgam (D2393) and unspecified 
preventive service (D1999) provided on December 2, 2020. 
 
You asked the Plan to pay an additional amount for the dental services. You say that the copay should have 
been $25 for your visit. The Plan denied your request. The Plan says you pay 50% for fillings received in 
network. The Plan says that the contracted rate for a filling is $198. The Plan says they paid 50% of the 
contracted rate or $99. The Plan also says that unspecified preventive service is not a covered service. 
 
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 and fillings are listed as covered, there 
is a 50% coinsurance that applies. This is a contractual obligation you agreed to when you enrolled in the 
Plan's dental coverage. Additionally, unspecified preventive service is not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the amalgam 
(D2393) and unspecified preventive service (D1999) provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #15. 
 
You asked the Plan to pre-approve a crown on tooth #15. You say that you need approval to cover the hole in 
your tooth due to root canal. The Plan denied your request. The Plan says that that you received a crown on 
tooth #14 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. The Plan covers a crown on 
tooth #15 when the services are medically necessary and reasonable. 
 
We looked at the file and Plan rules. The file does not include any documentation indicating you have received 
a crown this year. You included documentation indicating you received a crown on tooth #14 on November 16, 
2021. Based on this information, we decided that the Plan's rules for coverage of a crown on tooth #15 have 
been met. Therefore, we decided that the Plan has to pre-approve a crown on tooth #15.  
 
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 pay for the crown (D2753) provided on November 1, 2021. 
 
You asked the Plan to pay for the crown (D2753). You say that there is crown coverage for codes D2751 and 
D2752, and titanium is noted as covered material. You say that although the material is not covered, you expect 
some savings for the dental work. The Plan denied your request. The Plan says the service is not a covered 
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. Therefore, we decided that the Plan does not have to pay for the crown 
(D2753) provided on November 1, 2021.