Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for durable medical equipment (DME) 
provided on August 31, 2022. 
 
You asked the Plan to waive the copayment for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME $4,522. The 
amount you are being asked to pay $904.40 ($4,522 x 20% = $904.40). This item/service falls within the 
durable medical equipment (DME) 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 
durable medical equipment (DME) provided on August 31, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) provided on 
June 6, 2022, to July 1, 2022. 
 
You asked the Plan to waive the copayment for SNF. 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 $0 per 
day for days 1 to 20 and a $167.50 copayment per day for days 21 to 58 for skilled nursing facility (SNF) Care.  
 
You have been asked to pay a $0 per day for days 1 to 20 and a $167.50 copayment per day for days 21 to 58 
for SNF. The total amount you are being asked to pay is $2,847.50 ($167.50 x 17days = $2,847.50). This 
item/service falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) provided on June 6, 2022, to July 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on August 17, 2022. 
 
You asked the Plan to waive the deductible for an office visit. You say that you are appealing the deductible 
applied to the office visit dated August 17, 2022. 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. Your 
contract with the Plan says that there is a $185 deductible which applies to physician services.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 
deductible which applies to physician services. This cost sharing is a contractual obligation that had not been 
met at the time an office visit was received on August 17, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for an office visit provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specific nutrition program challenge provided at the health 
club purchased on October 24, 2022. 
 
You asked the Plan to pay for a specific nutrition program challenge provided at the health club. You say that 
this program provided you education on nutrition. You also say it had coaching sessions, as well as videos 
available for additional information. The Plan denied your request. The Plan says this specific nutritional 
challenge does not qualify as a weight loss program. The Plan also says that there are not health professionals 
to supervise this challenge, and this is just additional health club benefits. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when health professionals are used to supervise the program..  
The Plans rules for coverage of gym benefits have not been met. The Plan rules say that a qualified weight loss 
program is a hospital-based or a non-hospital-based weight loss program that focuses on weight loss by 
modifying eating and physical activity habits and that requires participation in behavioral/lifestyle counseling 
with nutritionists, registered dieticians, exercise physiologists or other certified health professionals in multiple 
sessions throughout enrollment in the program. Therefore, we decided that the Plan does not have to pay for a 
specific nutrition program challenge provided at the health club purchased on October 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for biopsy of oral tissue (D7286) provided on April 25, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service was medically necessary for 
you to continue to be in good health. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the biopsy of oral tissue is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for biopsy of 
oral tissue (D7286) provided on April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided on August 1, 
2022. 
 
You asked the Plan to waive the copayment for telehealth services. You say that you disagree with 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 $10 
copayment for physician/practitioner services/covered visit.  
 
You have been asked to pay a $10 copayment for telehealth services. This item/service falls within the 
physician/practitioner services/covered visit 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 telehealth services provided on August 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic parental drugs (D9610), sinus augmentation 
(D7951), an endosteal implant (D6010), a second stage implant surgery (D6011), and sedation (D9223), 
provided on July 29, 2021, to August 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the rendered dental services are not covered benefits. 
 
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 therapeutic parental drugs (D9610), sinus augmentation (D7951), an endosteal implant (D6010), a second stage 
implant surgery (D6011), and sedation (D9223), provided on July 29, 2021, to August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
September 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 $35 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a $35 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 September 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the diagnostic eye ultrasounds provided on 
April 29, 2022. 
 
You asked the Plan to waive the copayments for the diagnostic eye ultrasounds. You say that you were charged 
additionally to see the doctor. 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 $125 
copayment for other Medicare-covered diagnostic radiology services, which includes ultrasounds.  
 
 
 
 
 You have been asked to pay a $65 copayment for diagnostic ultrasounds because the allowed amount for this 
service is less than $125 ($40.24 + $24.76 = $65). These items/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 copayments 
for the diagnostic eye ultrasounds provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 09, 2022. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 the office visit provided 
on August 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2751). 
 
You asked the Plan to pay for a crown. You say that this crown is medically necessary. The Plan denied your 
request. The Plan says dental x-rays were not submitted. 
 
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 a crown have been met. Dental x-rays 
were requested, but never received them. Therefore, we decided that the Plan does not have to pay for a crown 
(D2751).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there was no referral or authorization on file for the rendered 
services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on August 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission and an electroencephalogram 
(EEG). 
 
You asked the Plan to pre-approve inpatient admission and an EEG. 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 inpatient admission and an EEG. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the requested 
inpatient setting for 4 days cannot be determined to be reasonable and necessary for the enrollee at this time. 
Such services would otherwise exceed the enrollee's clinical needs at this interval, and it would not be the most 
appropriate level of service/care at which services could be provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission and an EEG have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient admission and an electroencephalogram (EEG).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for 
date of service December 29, 2021. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, and 88381. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says these codes are 
included in the facility payment and are 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 facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
and 88381. This means there is both a professional and technical component for the CPT code(s). In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88341, 
88342, 88360, and 88381. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88341, 88342, 88360, and 88381 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88341, 88342, 88360, and 88381 billed for date of service December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic footwear, mens shoe, oxford (L3219) and 
foot insert (L3000). 
 
You asked the Plan to pre-approve the foot orthotics. You say that this request was honored last year and 
denied this year. You also say that the pain persists, and nothing has changed in your coverage in this time 
frame. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear, mens shoe, 
oxford (L3219) and foot insert (L3000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic visit provided on January 31, 
2022, to March 31, 2022. 
 
You asked the Plan to waive the copayment for chiropractic visit. You say that this should be covered. 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 $15 
copayment for Chiropractic services. 
 
You have been asked to pay a $15 copayment for chiropractic visit. This item/service falls within the 
Chiropractic 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 chiropractic 
visit provided on January 31, 2022, to March 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0120, D0220, D0230) provided on 
September 15, 2022 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $500 dental benefit maximum allowance for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service the dental services. 
Therefore, we decided that the Plan does not have to pay for dental services (D0120, D0220, D0230) provided 
on September 15, 2022
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of a deep implant services coded 20680 
provided on June 28, 2022. 
 
You asked the Plan to pay for the removal of a deep implant services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 20680 is removal of implant; deep (eg, buried wire, pin, 
screw, metal band, nail, rod or plate). 
 
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 removal of a deep implant services. Our reviewer says 
that the documentation does not support that code 20680 is separately payable. Our reviewer found code 20680 
(a removal of a deep implant) was billed in addition to tumor excision. The operative report documents "the 
hardware was encountered, an old reconstruction plate, which was exposed inferiorly.  Posteriorly along the 
right ramus, the plate was then accessed. At his point, the screw heads were then drilled out and the plate was 
sectioned and removed".  This procedure was performed in addition to other services provided in same 
anatomical area, and in this case, CPT 20680 would not be reported separately, as it is inclusive to the primary 
procedure. If hardware removal is performed with another procedure involving the same area, then CPT 20680 
would not be reported separately. Therefore, code 20680 is not separately payable. 
 
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 removal of a deep implant service has not been met. Therefore, we decided 
that the Plan does not have to pay for the removal of a deep implant services coded 20680 provided on June 28, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on November 26, 2021. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. 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 lab testing provided on 
November 26, 2021.