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

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98940) and the 
office visits (99212) rendered by the out-of-network (OON) provider from August 1, 2022, through  
October 17, 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 chiropractic manipulative treatments (98940) and the office visits (99212) 
rendered by the out-of-network (OON) provider from August 1, 2022, through October 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99203) 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 that this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that in this case, the office visit provided by a 
licensed acupuncturist is not a covered benefit. However, the Plan contract does indicate that supplemental 
coverage is provided by the Plan for visits with a licensed acupuncturist for the treatment of any condition. The 
Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we decided that the 
Plan has to pay for the office visit (99203) provided on November 2, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the visual field exam provided on August 1, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the visual field exam. You say that you are requesting payment and seeking 
review. The Plan denied your request. The Plan says the provider was out-of-network and there was no prior 
authorization on file. 
 
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 
visual field exam. We found no exception that would require the Plan to pay for the visual field exam. 
Therefore, we decided that the Plan does not have to pay for the visual field exam provided on August 1, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the maxillofacial area 
(70486) and a consultation (76140) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that your copayment should be $60 for the x-ray. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the CT 
scan of the maxillofacial area and the consultation are 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 a 
computed tomography (CT) scan of the maxillofacial area (70486) and a consultation (76140) provided on 
August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental consultation (D9310) provided on October 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 a dental 
consultation (D9310) provided on October 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periodic oral evaluation (D0120) and prophylaxis  
adult (D1110) provided on September 30, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider was in-network 
and you were told even if they were not in-network the services would be covered. The Plan denied your 
request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when 
your services are received from an out-of-network provider. 
 
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. 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for periodic oral evaluation (D0120) and 
prophylaxis  adult (D1110) provided on September 30, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the head or brain. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says that a CT scan of the head or 
brain is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that a CT 
scan of the head or brain is medically necessary. Our physician reviewer found the enrollee has increasing 
mastoid pain and a CT of the sinuses may not have included the entire mastoids in the field of view. 
Considering the enrollee's symptoms, a request for a CT of the brain to look at the temporal bones in a patient 
with their symptoms is indicated and should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a CT scan of the head or brain.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha. 
 
You asked the Plan to pre-approve Repatha. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha.  
 
Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), bitewings 
(D0274), the panoramic radiographic image (D0330), and a resin-based composite (D2335) for tooth #8 
provided by an out-of-network provider on December 1, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing the dental services and 
the provider divided the procedure into 2 parts. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. 
 
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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for a comprehensive oral evaluation (D0150), 
bitewings (D0274), the panoramic radiographic image (D0330), and a resin-based composite (D2335) for tooth 
#8 provided by an out-of-network provider on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prophylaxis - adult (D1110), periodic oral 
evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - 
periapical each additional radiographic image (D0230), and bitewings - four radiographic images (D0274) 
provided on September 30, 2022. 
 
You asked the Plan to waive the coinsurance for the dental services represented by codes D1110, D0120, 
D0220, D0230, and D0274. You say that this is not your bill and you have submitted a copy of a billing 
statement from 2021. 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 100% 
coinsurance for the dental services represented by codes D1110, D0120, D0220, D0230, and D0274, provided 
out-of-network.  
 
You have been asked to pay a 100% coinsurance for the dental services represented by codes D1110, D0120, 
D0220, D0230, and D0274. Prophylaxis - adult (D1110) falls under the prophylaxis (cleaning) benefit 
category. Periodic oral evaluation - established patient (D0120) falls under the exams benefit category. 
Periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image 
(D0230) falls under the intraoral x-rays (inside the mouth) benefit category. Bitewings - four radiographic 
images (D0274) fall under the bitewing x-rays benefit category. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), intraoral - periapical first radiographic image (D0220), intraoral - periapical each 
additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided on 
September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on October 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure is medically necessary, and 
you did not know it was not a covered service. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the comprehensive periodontal evaluation 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on October 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the clinical documentation shows that the enrollee initially had acute clinical and 
functional status change and would have required assessment by skilled nursing/therapy; however, the enrollee 
did not have 60-day free window period thus additional daily skilled services would not be covered by 
Medicare or not appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
July 5, 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 the service provided was billed as 
maintenance therapy, which is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, the chiropractic manipulative treatment provided in 
this case is considered maintenance therapy as billed. Maintenance therapy is not a covered benefit.  Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) 
provided on July 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on July 25, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says payment is 
included in the facility payment. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance services to and from another hospital 
or freestanding facility are covered under Part A. They are covered by the prospective payment rate or reimbursed as reasonable costs under Part A to hospitals excluded from PPS. 
 
We looked at the file and Medicare rules. The records show the enrollee was an inpatient when the ambulance 
services were provided. As such, payment for the transportation is included under Part A payment. Based on 
this information, we decided that Medicare rules for coverage of the ambulance services have not been met. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing identified with code G0481 provided on June 
20, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the drug testing billed is not supported. 
 
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 G0481 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation does not 
support 8-14 drug classes were tested. The documentation only supports 7 drug classes were tested This means 
code G0481 is not supported. Based on this information, we decided that Medicare rules for coverage of the 
drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
identified with code G0481 provided on June 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99233) provided on June 10, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
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 the services have been met. The 
submitted documentation does not contain medical records from the non-contract provider for the billed date of service. Therefore, we decided that the Plan does not have to pay for the services (99233) provided on June 10, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for tooth #12 and #13 provided on 
September 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to have the dental service done and 
the provider said it would be covered. The Plan denied your request. The Plan says the denial of payment for 
the core buildup is correct because there were no crowns for either tooth ever documented. Therefore, the core 
build 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 core buildup is not covered under 
the Plans dental benefit when it is not done to retain a crown on a tooth. Therefore, we decided that the Plan 
does not have to pay for core buildup (D2950) for tooth #12 and #13 provided on September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation-problem focused (D0140) provided 
on September 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the crown was absolutely necessary to eat or 
chew food without pain or a more expensive post installation due to going without a crown. The Plan denied 
your request. The Plan says a problem-focused limited oral evaluation is not on the list of covered services. 
 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 a limited 
oral evaluation-problem focused (D0140) provided on September 20, 2022.