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

 
We decided that the Plan does not have to waive the cost share for specialist office visits, x- rays, Medicare 
Part B drugs, and bone mass testing provided from October 14, 2021, to November 29, 2021. 
 You asked the Plan to waive the cost share for specialist office visits, x- rays, Medicare Part B drugs, and bone 
mass testing. You say that you cannot afford all these charges. 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 20% 
coinsurance for Medicare Part B prescription drugs, a $30 copayment for x-rays, $50 copayment for bone mass 
testing and a $20 copayment for specialist visits. 
 
You have been asked to pay a total of $166.35 for specialist office visits, x- rays, Medicare Part B drugs, and 
bone mass testing. These items/services fall within the Medicare Part B prescription drugs benefit category, 
Outpatient diagnostic tests and therapeutic services and supplies benefit category and Physician/Practitioner 
services, including doctors 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 cost share 
for specialist office visits, x- rays, Medicare Part B drugs, and bone mass testing provided from October 14, 
2021, to November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on October 16, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says generally, the enrollee must obtain their treatment from network providers. 
However, some exceptions apply, such as if the enrollee requires emergency services or urgently needed 
services when the network is not available (generally, when the enrollee is out of the service area), and out-of-
area dialysis services. In these circumstances, prior authorization to seek out-of-network treatment is not 
required. 
 
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 office visit provided on October 16, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Via Disc. 
 
You asked the Plan to pre-approve Via Disc. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 Via Disc. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Via disc is experimental. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Via Disc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Via Disc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 16, 2022. 
 
You asked the Plan to pay for an office visit. You say that you depend upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the patients insurance. The Plan denied your request. 
The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s).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, we 
decided that the Plan does not have to pay for an office visit provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 16, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on November 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says generally, the enrollee must obtain their treatment from network providers. 
However, some exceptions apply, such as if the enrollee requires emergency services or urgently needed 
services when the network is not available (generally, when the enrollee is out of the service area), and out-of-
area dialysis services. In these circumstances, prior authorization to seek out-of-network treatment is not 
required. 
 
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 office visit provided on November 11, 2021, by an 
out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided on January 24, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for emergency room services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of our plans network) will not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The 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 emergency room services provided on January 24, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images including 
bitewing provided on August 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you need the services provided because you had 
a toothache. You say that you can afford to pay the bill. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes the 
requested full mouth or panoramic x-rays but is limited to one procedure code every five calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a complete series of full mouth or panoramic x-ray which made your benefit exhausted on 
date of service June 6, 2022. Therefore, we decided that the Plan does not have to pay for intraoral - complete 
series of radiographic images including bitewing provided on August 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) 
provided on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that your tooth fell out and it hurt where it came out. 
The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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 pay for the 
removal of residual tooth roots (cutting procedure) provided on August 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. 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, for 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 April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete mandibular denture provided on April 
22, 2022. 
 
You asked the Plan to pay for the dental services. You say that your plan pays for restorative work, which you 
had done on your dental implant dentures. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental 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 pay for the reline 
complete mandibular denture provided on April 22, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 29819, 29823) provided to the 
enrollee on January 4, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the records do not support the services 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 
the denied codes is: 
 
CPT 29819: 
 
Arthroscopy, shoulder, surgical; with removal of loose body or foreign body 
 
CPT 29823: 
 
Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, 
humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, 
labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, 
foreign body[ies]) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the surgical procedure cites the 
glenoid was evaluated and had a greater than 5mm loose body that was floating. This was removed in whole 
and documented with arthroscopic images. This was greater than 5mm and did require another cannula to be 
placed. Therefore, the records do support that CPT 29819: arthroscopy of the shoulder surgery with removal of 
loose body or foreign body was a separate and distinct procedure from CPT 29827: arthroscopy, shoulder 
surgical, with rotator cuff repair. In terms of CPT 29823, the surgical procedure cites debridement was 
performed of the anterior, superior, and posterior labrum. The anterior interval and greater tuberosity were fully 
debrided in the area of full-thickness rotator cuff tear of the supraspinatus. The scope was placed in the 
subacromial space and the subacromial bursitis was debrided, uncovered the anterolateral hooked acromion, 
and debrided this to a stable flat base using the shaver-burr combination. Therefore, the records do support that 
CPT 29823 was rendered in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 29819, 29823) provided to the enrollee on January 4, 2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the influenza virus vaccine (90694) and administration 
(G0008) provided on February 1, 2022. 
 
You asked the Plan to pay for procedure codes 90694 and G0008. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Codes 90694 and G0008 are influenza vaccine and administration 
and are considered preventive health services. Per Medicare rules, when these services are provided in a RHC, 
the costs should not be included on the claim. Therefore, we decided that the Plan does not have to pay for the 
influenza virus vaccine (90694) and administration (G0008) provided on February 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 
31, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you shouldnt have to 
pay for 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B drugs. This item/service falls 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 
Medicare Part B drugs provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic lab services provided from 
February 10, 2022, to March 14, 2022. 
 
You asked the Plan to waive the copayment for diagnostic lab services. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment per visit for outpatient diagnostic tests/diagnostic lab services.  
 
You have been asked to pay a $5 copayment per visit for diagnostic lab services. The total you are being asked 
to pay is $15 ($5 x 3visit = $15). 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 diagnostic lab services 
provided from February 10, 2022, to March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lenses fitting provided on July 26, 2022. 
 
You asked the Plan to pay for the contact lenses fitting. You say that you are appealing the denial of the contact 
lenses fitting. The Plan denied your request. The Plan says the service is not a covered benefit. 
  
 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover the contact lenses fitting. 
 
We looked at the file and the Plan's rules. Specifically, the contact lenses fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lenses fitting have not been 
met. Therefore, we decided that the Plan does not have to pay for the contact lenses fitting provided on July 26, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device provided on July 2, 2022. 
 
You asked the Plan to pay for the TENS device. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim is missing documentation 
required for payment. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. In this case, the medical records do not indicate the ordering provided discussed the ordered 
equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the 
transcutaneous electrical nerve stimulation (TENS) device provided on July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on May 17, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you shouldnt have to pay 
for 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 $25 
copayment for Specialist office visits. 
 
You have been asked to pay a $25 copayment for specialist office visit. This item/service falls within the 
Specialist 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 specialist 
office visit provided on May 17, 2022.