Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for intraoral imaging. We decided that the Plan does 
not have to waive the coinsurance for intraoral imaging.  
 
You asked the Plan to waive the coinsurance for intraoral imaging (D0210) provided on June 21, 2022. You 
say that you were never told this provider was out-of-network. The Plan says that this cost sharing was charged 
correctly. 
 
 
 We decided that the Plan has to reduce the coinsurance for intraoral imaging.  
 
The Plan follows Medicare rules. Medicare rules say that there is a 20% coinsurance of the allowed amount for 
intraoral imaging. The total allowed amount is $89.64. The total amount you are being asked to pay is $17.93 
($89.64 x 20% = $17.93) Therefore, we decided that the Plan has to waive the coinsurance for intraoral 
imaging.  
 
We also decided that the Plan does not have to waive the coinsurance for intraoral imaging. 
 
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 intraoral imaging. Therefore, we decided that the Plan does not have to waive the coinsurance 
for intraoral imaging. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for services on November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that clinical evidence supports the testing. The Plan 
denied your request. The Plan says the service is not supported by the procedure codes 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. 
 In this case, the CPT Code Manual definition of code 81210 is BRAF (B-Raf proto-oncogene, serine/threonine 
kinase) (e.g., colon cancer, melanoma), gene analysis, V600 variant(s). We find that CPT code 81210 is not 
supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the 
lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
billed for services on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core (D2954) provided by a 
participating provider. 
 
You asked the Plan to pre-approve a prefabricated post and core. You say that you were told that you would be 
covered after your $50 deductible. The Plan denied your request. The Plan says the requested dental 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 pre-approve a 
prefabricated post and core (D2954) provided by a participating provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services (71045 and 74018) provided on 
January 15, 2022. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from January 
15, 2022, to January 16, 2022. The Plan says, per Medicare guidelines, the provider must bill Original 
Medicare for the services provided on January 15, 2022. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the radiology services (71045 and 74018) provided on 
January 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided by a participating 
provider on February 15, 2022, and May 23, 2022. 
 
You asked the Plan to pay for periodontal maintenance. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says the denied dental 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 
periodontal maintenance (D4910) provided by a participating provider on February 15, 2022, and May 23, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77065 billed for date of service April 21, 
2022.  
You asked the Plan to pay for procedure code 77065. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 77065 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 77065 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 77065 billed for date of service April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided by a 
participating provider on July 25, 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 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 January 22, 2020. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided 
by a participating provider on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry 
services coded 83789 provided on January 31, 2022. 
 
You asked the Plan to pay for the mass spectrometry and tandem mass spectrometry services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit. 
 
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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, this service was billed with 
codes G0481 and 80307 (drug testing services). Providers performing validity testing on urine specimens 
utilized for drug testing should not separately bill the validity testing. Therefore, code 83789 is not separately 
payable. This service not separately payable Based on this information, we decided that Medicare rules for 
coverage of the mass spectrometry and tandem mass spectrometry services have not been met. Therefore, we 
decided that the Plan does not have to pay for the mass spectrometry and tandem mass spectrometry services 
coded 83789 provided on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit. 
 
You asked the Plan to pre-approve a specialist office visit. You say that treatment has been ongoing since 
November 3, 2014. You also say that during your follow up visit appointment on October 3, 2022, it was 
determined that the member requires follow up visits to monitor symptoms and necessary adjustment to the 
occlusal orthotic splint. The Plan denied your request. The Plan says services for temporomandibular joint 
(TMJ) disorder are not covered under the enrollee's health 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 pre-approve a 
specialist office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your lower denture, and you need 
a new denture. 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 the date of service of February 16, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ER follow up provided from February 24, 2022, to August 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an ER follow up. You say that you didn't know this provider was out-of-network 
and would have gone elsewhere had you known. 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 an ER follow up provided from February 24, 
2022, to August 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 copayment for office visit on August 23, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you want to appeal the amount being 
charged. 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 $10 
copayment per visit for primary care physician (PCP).  Covered services include medically necessary medical 
care or surgery services furnished in a physicians office, certified ambulatory surgical center, hospital 
outpatient department, or any other location. Consultation, diagnosis, and treatment by a specialist. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the 
Physician/practitioner services, including doctor's office visits 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 office visit on August 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on June 19, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a physical therapy visit. You say that you would like the denied claim for 
services rendered on June 19, 2021, to be reconsidered. The Plan denied your request. The Plan says an 
authorization was not obtained prior to 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 a physical therapy visit provided on June 19, 2021, 
by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 
You asked the Plan to pre-approve Leqvio. 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 must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Leqvio. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the Food and Drug Administration has not 
stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 9, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member must receive care from a network provider or it will not be covered except for urgent/emergency care, 
approval to see an out-of-network doctor, or kidney dialysis services from a Medicare-certified dialysis facility 
outside the Plans service area. In this case, prior authorization was not obtained. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service July 11, 
2022. 
 You asked the Plan to pay for procedure code 71260. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 71260 is bundled into payment for code 71275. 
 
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 71260 
is a column II code to column I code 71275. 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 71260 billed for date of service July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) on 
September 14, 2022. 
 
You asked the Plan to waive the copayment for MRI. You say that you want to appeal the amount being 
charged. 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 $300 
copayment for each Medicare-covered service for outpatient diagnostic. Covered services include, but are not 
limited to diagnostic Imaging (CT scan, MRI/MRA, Myocardial Nuclear Perfusion Imaging and PET scans). 
The provider billed in the amount of $1.226 and the allowed amount is $231.98. This is less than the 
copayment amount. Therefore, results in the total cost sharing amount of $231.98.  
 
 
 
 
 You have been asked to pay a $231.98 copayment, which is less than the copayment for MRI. This item/service 
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 magnetic resonance imaging (MRI) on September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established 
patient (D0150), and extraction erupted tooth requiring removal of bone and/or sectioning of tooth and 
including elevation of mucoperiosteal flap if indicated (D7210). 
 
You asked the Plan to pre-approve the comprehensive oral evaluation - new or established patient (D0150), and 
extraction erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210). You say that you need the extraction because part of your tooth fell 
off, and you were referred to an oral surgeon. The Plan denied your request. The Plan says your request for 
authorization for a tooth extraction with an oral surgeon is a non-covered service. 
 
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 when provided by an oral surgeon. Therefore, we decided that the Plan 
does not have to pre-approve a comprehensive oral evaluation - new or established patient (D0150), and 
extraction erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2750) and core buildup (D2950). 
 
You asked the Plan to pre-approve a porcelain crown (D2750) and core buildup (D2950). You say that on the 
page for dental benefits in the 2022 plan changes and enhancement, it clearly mentioned that you have $1,000 
for services including restorative treatments. You also say that a crown is considered a restorative treatment. 
The Plan denied your request. The Plan says these services are 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, 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 a 
porcelain crown (D2750) and core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on May 
23, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not be 
responsible to pay 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 diagnostic colonoscopy. 
 
You have been asked to pay a $200 copayment for a diagnostic colonoscopy. This item/service falls within the 
diagnostic colonoscopy 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 
diagnostic colonoscopy provided on May 23, 2022.