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

We decided that the Plan does not have to waive or reduce the cost share for out of network dental services
provided August 10, 2022, to September 9, 2022.
You asked the Plan to waive or reduce this cost share. You say that these dental services should be paid for by
the Plan as it was believed the provider was in network. The Plan denied your request. The Plan says the cost of
the services provided were partially overturned and reprocessed. Because these are out of network providers,
the contract is clear that your cost share could be higher for these services.
The Plan states code D7140 the extraction for tooth number 10, erupted tooth or exposed root and D5213,
maxillary partial denture has now been covered at the in-network rate with only the applicable cost share for
dentures being required. As for code D7140 extraction, erupted tooth or exposed root for tooth number 29, a
tooth history and past Explanation of Benefits was found and that tooth had a crown placed on it on June 20,
2011, and then on February 18, 2013, removal of residual tooth roots were performed. Therefore, the tooth 29
extraction is being upheld as an exhausted benefit. In addition, the Plan records indicate you did not contact the
Plan prior to the date of service to verify benefits and provider eligibility. For those reasons, the Plan will only
be sending partial reimbursement.
The Plan is correct in this case. Medicare generally does not cover dental services. However, the Plan offers a
dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan contract states prior authorization rules apply for dental services. The Plan contract states cost share
for out of network services will be higher. The Plan contract states there are benefit limitations to the services
provided and that the cost share for dentures is a 50% coinsurance both in and out of network. Review of the
case file and the records provided by the Plan shows these services were processed correctly. The Plan applied
a partial reimbursement for the confusion regarding the providers network status. The Plan applied the
appropriate coinsurance for dentures and the Plan denied coverage for code D7140 on tooth number 29 due to
an exhausted benefit.
Therefore, we decided that the Plan does not have to waive or reduce the cost share for out of network dental
services provided August 10, 2022, to September 9, 2022 (D7140 for tooth number 29, the cost share applied to
code D5213 and the cost difference between the charged amount and the allowed amount for code D7140 for
tooth number 10).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 13, 2022. 
 
You asked the Plan to pay for office visit. You say that the provider you saw is in-network, so this visit should 
be covered. 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). Therefore, we decided that the Plan does not have to pay for office visit provided on 
July 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiac procedure provided on 
September 26, 2022. 
 
You asked the Plan to waive the copayment for the cardiac procedure. You say that you already met your out-
of-pocket maximum. 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 $250 
copayment for each Medicare-covered surgery at an outpatient hospital facility. 
 
You have been asked to pay a $54.10 copayment for the cardiac procedure because your out-of-pocket 
maximum was met once the cost sharing applied. This item/service falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the cardiac procedure provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and an electrocardiogram provided on 
November 28, 2022. 
 
You asked the Plan to pay for an office visit and an electrocardiogram. You say that you were told the provider 
accepted your 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). Therefore, we decided that the Plan does not have to pay for an office visit and an 
electrocardiogram provided on November 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 6, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. 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 $130 
copayment for outpatient diagnostic tests/Medicare-covered radiological diagnostic services.  
 
You have been asked to pay a $130 copayment for an ultrasound. However, you are only being asked to pay 
$78.90 which is less than the required amount. This item/service falls within the outpatient diagnostic 
tests/Medicare-covered radiological diagnostic 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 ultrasound provided on October 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colonoscopy provided on September 20, 2022. 
 
You asked the Plan to pay for colonoscopy. You say that you are appealing the claim payment denial. 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). Therefore, we decided that the Plan does not have to pay for colonoscopy provided 
on September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx test (0239U) provided on 
March 7, 2022. 
 You asked the Plan to pay for the FoundationOne Liquid CDx test. You say that this FDA-approved testing 
was medically necessary. The Plan denied your request. The Plan says the enrollee has been previously tested 
with the same test and does not have a new cancer diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that to be covered, the enrollee must have either not 
been previously tested using the same NGS test for the same primary diagnosis of cancer or repeat testing using 
the same NGS test only when a new primary cancer diagnosis is made by the treating physician 
 
We looked at the file and Medicare rules. In this case the enrollee has been previously tested with the same 
NGS test in 2021 and does not appear to have a new primary cancer diagnosis. Based on this information, we 
decided that Medicare rules for coverage of the FoundationOne Liquid CDx test have not been met. Therefore, 
we decided that the Plan does not have to pay for the FoundationOne Liquid CDx test (0239U) provided on 
March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
November 2, 2022. 
 
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 this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or 
re-bond of a crown (D2920) provided on November 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88381 billed for 
date of service February 24, 2022. 
 You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88381. You say that you are an 
independent laboratory that provides molecular diagnostic services to cancer patients. The Plan denied your 
request. The Plan says this code is included in the skilled nursing facility payment and is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code 88341, 88342, 88360, 88381 has a Professional/Technical indicator of 1. This means that 
CPT code 88341, 88342, 88360, 88381 has both a professional and technical component. In this case, CPT 
code 88341, 88342, 88360, 88381 has not been billed with an appropriate modifier to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of procedure code 88341, 
88342, 88360, 88381 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 88341, 88342, 88360, 88381 billed for date of service February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service October 23, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Monovisc injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says you are required to try other medications first. The Plan states you 
must try and fail other drugs that are indicated for treating your condition. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the Plan requires a trial of drug(s) Euflexxa, Durolane, Supartz-FX and Gelsyn-3 before they will 
approve the requested drug, Monovisc. Based on the medical records provided there is no indication that you 
have tried and failed the required drug(s). Based on the medical records provided and the Medicare-approved 
major drug compendia there is no indication that the Plan's required drug(s) would likely be less effective 
and/or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Monovisc injection.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 13, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says the provider must 
attempt to consult the attending or primary care physician about the services furnished and document the 
consent or declination date to consultations, and the date of consultations in the patients medical record. There 
was no documentation of contact in the patient record. 
 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76642 billed for date of service October 21, 
2022. 
 
You asked the Plan to pay for procedure code 76642. You say that this claim denied as a duplicate in error. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76642 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76642 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76642 billed for date of 
service October 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and are supported in 
the medical records. 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 May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64416 billed for date of service October 19, 
2022. 
 
You asked the Plan to pay for procedure code 64416. You say that you disagree with the 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 64416 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 64416 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 64416 billed for date of service October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visit provided on July 12, 2022. 
 
You asked the Plan to pay for specialist office visit. You say that you have gone to this provider in the past and 
you do not have time to verify what providers are in-network. 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). Therefore, we decided that the Plan does not have to pay for specialist office visit 
provided on July 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 10, 2022, to 
June 27, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, we find that 
the first Q code line and first G code line were not billed with the same date of service. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from June 10, 2022, to June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient care provided on September 13, 
2022, and September 14, 2022. 
 
You asked the Plan to waive the copayment for inpatient care. You say that you went to the emergency room 
and were not in a hospital room. 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 $325 
copayment per day for days 1 to 5 of inpatient hospital care. 
 
You have been asked to pay a total of $650 for inpatient care ($325 copayment per day x 2 days = $650). The 
medical records support that you were admitted as an inpatient for the dates of service at issue, meaning these 
services fall within the inpatient hospital 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 inpatient care provided on September 13, 2022, and September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient care provided from September 4, 
2022, to September 6, 2022. 
 
You asked the Plan to waive the copayment for inpatient care. You say that you were not taken to a room until 
September 5, so you should not have this 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 $375 
copayment each day for days 1 to 5 of inpatient hospital care. 
 
You have been asked to pay a total of $750 for inpatient care ($375 copayment per day x 2 days = $750). This 
item/service falls within the inpatient hospital 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 inpatient care provided from September 4, 2022, to September 6, 2022.