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

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 6, 
2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be treated as a covered 
charge. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment  for the ultrasound.  
 
You have only been asked to pay $97.84 for the ultrasound. The allowed amount was only $97.84 reducing 
your copayment obligation. Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services 
and Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on 
January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 24, 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 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 July 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presumptive drug class screening (80307) and definitive drug 
testing (G0483) provided June 11, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached claim and accept 
this as a medical necessity appeal. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of presumptive Drug Class Screening 
(80307) and definitive drug testing (G0483) provided June 11, 2021 have been met. In this case, additional 
records was required to determine how the enrollee came to the servicing provider and to support medical 
necessity of the services. The records show that the Plan made multiple attempts to obtain the records from the 
provider without success. Therefore, we decided that the Plan does not have to pay for presumptive drug class 
screening (80307) and definitive drug testing (G0483) provided June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray 
(D0330), maxillary partial denture (D5211), and complete mandibular overdenture (D5865) provided on 
September 4, 2021, and September 18, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the comprehensive oral evaluation, panoramic x-ray, maxillary partial denture, 
and complete mandibular overdenture. You say that you saw an in-network dentist who advised you needed to 
go back to the dentist who did your dental work and submitted a referral to return to that dentist. The Plan 
denied your request. The Plan says the Plan will not authorize payment of denied dental claim. The Plan also 
says that payment was denied because the services in question were not emergent or emergent and services 
were provided by a non-contacted dentist. 
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 because they were not provided on an emergency basis by the OON 
provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation 
(D0150), panoramic x-ray (D0330), maxillary partial denture (D5211), and complete mandibular overdenture 
(D5865) provided on September 4, 2021, and September 18, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) 
provider on October 1, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on October 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308), the 
subcutaneous tissue debridement (11042), and the chemical cauterization of granulation tissue (17250) 
rendered by the out-of-network (OON) provider on January 5, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 subsequent nursing facility care, per day (99308), the subcutaneous tissue 
debridement (11042), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-
network (OON) provider on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management services (99239) 
provided on August 21, 2021. 
 
You asked the Plan to pay for code 99239. 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. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes.  
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. To bill CPT 99239, the documentation must note that more than thirty minutes was spent providing 
services to the enrollee on the day of discharge. The progress note for August 21, 2021 does not note how 
much time was spent providing services to the enrollee. As such, the provided documentation does not support 
the billing of code 99239. Based on this information, we decided that Medicare rules for coverage of code 
99239 have not been met. Therefore, we decided that the Plan does not have to pay for the Hospital discharge 
day management services (99239) provided on August 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis services (20610, 77002) 
provided on December 15, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a $50 copayment for the arthrocentesis services. Arthrocentesis services fall 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 arthrocentesis services (20610, 77002) provided on December 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray (73564) provided on December 
10, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $95 copayment for the x-ray. X-rays fall within the Outpatient hospital services 
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 x-ray (73564) provided on 
December 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a foot x-ray provided on December 2, 
2021. 
 
You asked the Plan to waive the copayment for a foot x-ray. You say that you had to have a post-op x-ray of 
your foot. You also say that you feel the claim was not billed correctly. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for an in-network x-ray taken at a specialist's office.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $32.75, which is less than the $35 copayment for a foot x-ray. A foot x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a foot x-ray provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on October 5, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cardiovascular screening tests (81404, 81479) 
provided on January 11, 2021. 
 
You asked the Plan to pay for hereditary cardiovascular screening tests. You say that this was medically 
necessary. The Plan denied your request. The Plan says this was not ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
(CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 
 
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not 
covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular 
screening tests have not been met. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular screening tests (81404, 81479) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the replacement denture (D5130), and lab fee 
(D0999) provided from October 20, 2021, to October 27, 2021. 
 
You asked the Plan to reimburse you for the dental item. You say that you wear a full upper denture. You say 
that you were in an accident resulting in your denture breaking. You say that you would like this to be covered 
under your medical coverage. You also say that this bill is a lot for you. The Plan denied your request. The Plan 
says dental services are not covered unless related to wiring of the jaw after a fracture or for cancer. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to reimburse you 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 reimburse you for the 
replacement denture (D5130), and lab fee (D0999) provided from October 20, 2021, to October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on  
November 17, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99336) rendered by the out-of-network (OON) provider on July 9, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99336) rendered by the out-of-network (OON) provider on July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prosidyan Fibergraft allograft. 
 
You asked the Plan to pre-approve Prosidyan Fibergraft. You say that the enrollee's symptoms are worsening 
and causing difficulty. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because the clinical value and effectiveness of Prosidyan Fibergraft has not been demonstrated. 
 
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 Prosidyan Fibergraft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows 
Prosidyan Fibergraft allograft to be an effective and safe treatment in association with decompressive 
laminectomy/fusion. There is no compelling rationale presented or extenuating circumstance noted to support the medical necessity of this procedure as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prosidyan Fibergraft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Prosidyan Fibergraft allograft.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on December 18, 
2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the doctors office was 
closed and the walk-in clinic would not treat you.  You say that they suggested I go to another clinic or the 
hospital. The Plan denied your request. The Plan says you have been charged the correct copayment amount. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a $90 copayment for emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. Emergency room visits fall 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 on December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on February 24, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 laboratory services rendered by the out-of-network (OON) provider on 
February 24, 2022.