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

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) and 
adjunctive pre-diagnostic test (D0431) provided on June 7, 2021. 
 
You asked the Plan to pay for the complete series of intraoral x-rays and adjunctive pre-diagnostic test. You 
say that the dental office should have informed you of any service being done during your appointment that 
would not be covered under your plan. The Plan denied your request. The Plan says these services are not 
covered. The Plan also says that when you contacted the Plan prior to this date of service, there was no 
discussion on coverage for these services, and you were educated that the services that are covered are code 
specific. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The only type of x-rays covered under your plan are bitewing x-rays. 
Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) 
and adjunctive pre-diagnostic test (D0431) provided on June 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you have not had a change in function warranting daily skilled therapy. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 
10, 2021. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that your medical plan states that it 
will pay for a specialist office visit, minus the $25 copay. You also say that you would like the Plan to pay for 
the consultation office visit as it should. The Plan denied your request. The Plan says this service is considered 
to be routine dental care. The Plan also says that routine dental care is not a covered service. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral 
evaluation (D0150) provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on 
January 20, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular risk assessment testing provided on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided an out-of-network provider on 
July 5, 2021. 
 
You asked the Plan to pay for the vision services. You say that you delivered the referral request and was 
assured that the doctor would provide the referral promptly. You say that you followed the proper procedure, 
and the denial should be reconsidered. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and the services 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 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 vision services provided an out-of-network 
provider on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services provided on April 12, 2021.  
You asked the Plan to pay for the services provided. You say that the records prove medical necessity. The 
Plan denied your request. The Plan says the records did not support the services.  
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 99223 is initial hospital care, typically 70 minutes. We 
find that CPT code 99223 is not supported in the medical record. The records do not indicate that at least 70 
minutes were spent at the bedside of the enrollee. Based on this information, we decided that Medicare rules 
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to 
pay for the initial hospital care services provided on April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on June 29, 2021. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that you were only told that you were required to pay a copay of $39, which you paid on the day of 
these services. You also say that you would like these services to be paid in full. The Plan denied your request. 
The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this 
date of service to verify benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on June 
29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 
25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on May 25, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices (E0673, E0675) 
provided on April 23, 2021. 
 
You asked the Plan to pay for intermittent limb compression devices. You say that the items at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare for prevention of deep vein thrombosis or pulmonary embolism. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
devices (E0673, E0675) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth physician visit provided on March 26, 2021, by 
an out-of-network provider. 
 
You asked the Plan to pay for a telehealth visit. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that out-of-network telehealth is not covered. 
 
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 services at issue in this appeal.  
 
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 a telehealth physician visit provided on March 26, 2021, by an out-of-network 
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology provided on June 23, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgical pathology. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 surgical pathology provided on June 23, 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 acupuncture rendered from April 7, 2021 to May 13, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plan's rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the file shows that the acupuncture was performed for 
the treatment of osteoarthritis, not chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for the acupuncture rendered from April 7, 2021 to May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99201) chiropractic manipulative 
treatment (98943) provided February 17, 2021. 
 
You asked the Plan to pay for the chiropractic services. You say that had you been made aware of this billing 
code issue you never would have gone to this particular chiropractor. The Plan denied your request. The Plan 
says this service is not covered when rendered by a chiropractor. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99201) chiropractic manipulative treatment 
(98943) provided February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on May 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that the service should be covered. The Plan denied 
your request. The Plan says the testing is considered redundant to the testing allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
indications for coverage have been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on June 16, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you would like to be reimbursed 
$146.00 for this service. The Plan denied your request. The Plan says this service was rendered by an OON 
provider. The Plan also says that your plan does not cover services from a provider who is not in-network. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resin-
based composite (D2393) provided on June 16, 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 physician services provided on December 23, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 physician services provided on December 23, 
2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions (D7140 x 11) provided on January 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had to have 11 teeth removed due to 
radiation treatments. You also say that you feel this should be covered since the procedure was done in the 
hospital operating room. The Plan denied your request. The Plan says the extractions are not listed as covered 
services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the extractions are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions (D7140 
x 11) provided on January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crown (D6740) and adjunctive procedures 
(D9999) provided on February 8, 2020, and February 10, 2020. 
 
You asked the Plan to pay for the retainer crown and adjunctive procedures. You say that in November 2020 
you contacted the Plan and were advised that the dental services you received in Mexico were covered. You 
also say that later you were told that because the work was provided in Mexico, it was not covered. The Plan 
denied your request. The Plan says you received these services from a dental provider located in Mexico. The 
Plan also says that reimbursement cannot be issued because you elected to receive the dental services from a 
foreign provider outside of the United States. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered because services are only covered when they are rendered by a provider who accepts Medicare patients 
in the United States. Therefore, we decided that the Plan does not have to pay for the retainer crown (D6740) 
and adjunctive procedures (D9999) provided on February 8, 2020, and February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 5, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 
87581, 87640) provided on September 16, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed with the correct Plan of service. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 11 for an office setting, but 
the record shows that the sample was taken in a nursing facility. Based on this information, we decided that 
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does 
not have to pay for laboratory services (87486, 87496, 87498, 87532, 87541, 87581, 87640) provided on 
September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test you had on February 
26, 2021. 
 
You asked the Plan to waive the copayment for the nuclear stress test. You say that there should not have been 
a copayment for this stress test.  You stated that the only reason why you have a copayment is because you 
could not run and they did a different time of testing where you were sitting down. The Plan denied your 
request. The Plan says you were charged this copayment 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 $95 
copayment for diagnostic and nuclear medicine radiological services.  
 
You have been asked to pay a $95 copayment for the nuclear stress test. The nuclear stress test falls within the 
diagnostic and nuclear medicine radiological services benefit category. This copayment applies regardless of 
the reason for the test. 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 nuclear stress test you had on 
February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct admission rendered on April 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded. 

We looked at the file and Medicare rules. Billed procedure code G0379 (direct admission of patient for hospital 
observation care) has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the direct admission rendered on April 14, 2021.