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

 
We decided that the Plan does not have to pay for an office visit provided on November 9, 2021. 
 
You asked the Plan to pay for the office visit. You say that you did not know the provider was not in-network 
and you were under the impression that a referral or prior authorization was not required. The Plan denied your 
request. The Plan says you must receive your care from a network provider. In most cases, care you receive 
from an out-of-network provider will not be covered except for emergency care or urgently needed services 
that you get from an out-of-network provider; if you need medical care that Medicare requires the Plan to cover 
and the providers in our network cannot provide this care, you can get this care from an out-of-network 
provider. In most cases, a prior authorization should be obtained from the Plan prior to seeking care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 an office visit provided on November 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the pelvic ultrasound (76856) and the 
transvaginal ultrasound (76830) provided on April 20, 2021. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
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 deductible of $500. This is the amount you have to 
pay out-of-pocket before the Plan will pay their share for your covered medical services. Until you have paid 
the deductible amount, you must pay the full cost of your covered services. Once you have paid your 
deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay 
your copayment or coinsurance amount for the rest of the calendar year.  
 
You have been asked to pay $296.35 ($148.64 + $147.71) for the radiological diagnostic services provided as 
you had not previously met the annual deductible. This is the Plans allowed amount for the services provided.  
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 deductible for the pelvic ultrasound (76856) and the 
transvaginal ultrasound (76830) provided on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7140 x 10), immediate upper denture 
(D5130), immediate lower denture (D5140), and implants (D6010 x 2) provided on November 17, 2021, by the 
out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you thought you would be reimbursed $2,100 
for the services you had done. The Plan denied your request. The Plan says dental services received out of 
network are not covered. 
 
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, dental services received out of network 
are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the extractions (D7140 x 10), immediate upper denture (D5130), immediate lower denture (D5140), and implants (D6010 x 2) provided on November 17, 2021, by the out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for tissue exam by pathologist (88305) 
provided on December 3, 2021. 
 
You asked the Plan to waive the copayment for tissue exam by pathologist. You say that the provider used a 
needle to perform the service, and the procedure took place in an ambulatory service center. The Plan denied 
your request. The Plan says you were 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 $375 
copayment per date of service for an in-network outpatient hospital facility.   
You have been asked to pay a $375 copayment for tissue exam by pathologist. Tissue exam by pathologist 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 tissue exam by pathologist 
(88305) provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam CT 
capture with interpretation (D0364) provided on December 22, 2021. 
 
You asked the Plan to pay for the dental services. You say that your tooth was infected and painful. You say 
that you were put on antibiotics and sent to a different provider. You also say that the services should be 
covered. The Plan denied your request. The Plan says a limited oral evaluation is covered once per plan year. 
The Plan says that the frequency limit has been exceeded. The Plan also says cone beam CT capture with 
interpretation is not listed as a covered service. 
 
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 and a limited oral evaluation is covered 
once per plan year, the frequency limit has been exceeded. The record shows that the Plan paid for a limited 
oral evaluation that you received on December 2, 2021. Additionally, the cone beam CT capture with 
interpretation is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation (D0140) and cone beam CT capture with interpretation (D0364) provided 
on December 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2740) provided May 7, 2021. 
 
You asked the Plan to pay for the dental services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your dental 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 requested items or services are not 
among those covered under this benefit.  
 
 
  
Therefore, we decided that the Plan does not have to pay for dental services (D2740) provided May 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of twelve (12) additional physical therapy 
(PT) visits (97110).  
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary The Plan denied your request. The Plan says the requested additional PT visits do not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had prior therapy and the documentation does not reveal that 
you require the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist. You can transition to an independent home exercise program with the approved additional 8 sessions 
and does not require the requested additional 12 sessions of formal therapy. The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve coverage of twelve (12) additional physical therapy (PT) visits (97110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital visit provided to the enrollee on September 21, 
2020. 
 
You asked the Plan to pay for the services. You say that this was sent to Workman's Compensation in error. 
The Plan denied your request. The Plan says the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until December 23, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a hospital visit provided to the enrollee on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial observation care (99220) provided on January 28, 
2021, and the subsequent observation care (99225) provided on January 29, 2021. 
 
You asked the Plan to pay for the observation services. You say that you just want this claim paid. The Plan 
denied your request. The Plan says your primary insurance plan is with another company. The Plan requires an 
explanation of benefits from your primary insurer to process this claim. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment.  Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the 
services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
outreach to yourself and to the provider with instructions on where to send the claim for payment. As the 
secondary insurer, the Plan cannot be held responsible for the observation services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the initial 
observation care (99220) provided on January 28, 2021, and the subsequent observation care (99225) provided 
on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342), localized 
delivery of antimicrobial agents (D4381) and gingival irrigation (D4921) provided on December 16, 2020. 
 
You asked the Plan to pay for the dental services. You say that your plan only states that out-of-network dental 
care is more expensive, not that it will be denied completely. The Plan denied your request. The Plan says these 
services are not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal scaling and root planing (D4342), localized delivery of antimicrobial agents (D4381) and gingival 
irrigation (D4921) provided on December 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Injection of Anesthetic Agent on October 
5, 2021. 
 
You asked the Plan to waive the copayment for Injection of Anesthetic Agent. You say that you do not have 
money for this. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $275 
copayment for Injection of Anesthetic Agent.  
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for Injection of Anesthetic Agent. Injection of Anesthetic Agent 
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 Injection of Anesthetic 
Agent on October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
April 3, 2021, to April 9, 2021. 
 
You asked the Plan to pay for the service. You say that this should be paid for. The Plan denied your request. 
The Plan says payment of DRG 871 is not supported, as the review supports DRG 872. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 pay for the 
service. Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found the diagnosis of sepsis was supported, from the information that was received; 
however, the documentation was insufficient regarding the diagnosis of septic shock. Reasonable support 
within the health record must be present for that diagnosis. The review has determined that payment of DRG 
871 is not supported, as the review supports DRG 872 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV 
>96 HOURS WITHOUT MCC).  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from April 3, 2021, to April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravenous (IV) infusion (code 96365) 
provided on August 6, 2021. We also decided the Plan does not have to waive the copayment for the collection 
of blood from an implantable venous access device (code 36591) on September 17, 2021. 
 
You asked the Plan to waive the copayment for venous access device collection and IV infusion. You say that 
you had to have your port flushed and the nurse did not state it was a special department or that there would be 
a charge. 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 $195 
copayment for outpatient surgery or other medical services provided to you at an outpatient hospital, including 
hospital or other facility charges.  The collection of blood from an implantable venous access device (code 36591) is considered a surgical 
procedure and an IV infusion (code 96365) is considered a medical service procedure. You have been asked to 
pay the allowed amount of $189.26, which is less than the $195 copayment for IV infusion on August 6, 2021. 
You have also been asked to pay the allowed amount of $104.12, which is less than the $195 copayment for 
venous access device collection. You have been asked to pay a total of $293.38 ($189.26 copayment + $104.12 
copayment = $293.38). Venous access device collection and IV infusion falls within the Outpatient Surgery 
and Other Medical 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 an intravenous (IV) infusion (code 96365) 
provided on August 6, 2021. We also decided the Plan does not have to waive the copayment for the collection 
of blood from an implantable venous access device (code 36591) on September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination and 
evaluation provided on November 19, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says 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 Plan says that the Plan has also determined 
that these services are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 ophthalmological services, medical examination and evaluation 
provided on November 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of impacted tooth, partially bony, (D7230) 
provided on April 29, 2021. 
 
You asked the Plan to pay for the dental service. You say that you feel this service was coded wrong. You say 
that an impacted tooth cannot be decayed like the tooth you had extracted. You also say that the service you 
received should be covered. The Plan denied your request. The Plan says removal of impacted tooth, partially 
bony, is not listed and therefore is not a covered service. 
 
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 removal of impacted tooth, 
partially bony, not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pay for the removal of impacted tooth, partially bony, (D7230) provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0480) rendered by the out-of-network (OON) 
provider on December 21, 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 (G0480) rendered by the out-of-network (OON) provider on  
December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the posterior fillings provided from 
August 2, 2021, to August 16, 2021. 
 
You asked the Plan to waive the cost share amount for the dental services. You say that you thought the fillings 
were covered. You say that you did not authorize the provider to do white fillings. You also say that you 
strictly remember telling them only use or do what your insurance will cover. The Plan denied your request. 
The Plan says the supplemental dental benefit allows for coverage of fillings based on the cost for amalgam 
material. The Plan also says that you are responsible for the difference in cost. 
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 and fillings are listed as covered, 
posterior fillings are paid at the rate of an amalgam. You are responsible for the difference between these 
amounts. Therefore, we decided that the Plan does not have to waive the cost share amount for the posterior 
fillings provided from August 2, 2021, to August 16, 2021.