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

 
We decided that the Plan does not have to waive the copayment for a surgical injection procedure provided on 
August 9, 2021. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you do not know why your 
portion for this bill went up to $400. The Plan denied your request. The Plan says the copayment amount you 
are being charged is 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 $400 
copayment for outpatient surgery at an outpatient hospital.   You have been asked to pay $400 copayment for outpatient surgery. Outpatient surgery 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 a surgical injection 
procedure provided on August 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from October 20, 2021, through 
October 31, 2021. 
 
 
 
 
 
 You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 13, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for SNF services 
provided from October 20, 2021, through October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction (D7140), limited oral exam (D0140), and 
intraoral x-rays (D0220, D0230) provided on December 6, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary, and the provider 
led you to believe these services would be covered. The Plan denied your request. The Plan says these services 
are not covered by the enrollee's 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 the extraction (D7140), limited oral exam (D0140), and intraoral x-rays (D0220, D0230) provided on December 6, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), periapical x-rays (D0220, D0230 x 2), adjunctive pre-diagnostic testing (D0431), and bitewing x-rays 
(D0274) provided on January 18, 2022 by the out of network provider. 
 
You asked the Plan to pay an additional amount for the dental services. You say that it is your understanding 
that you only pay 50% of the cost for out of network services. The Plan denied your request. The Plan says the 
claim processed correctly. 
 
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 oral exam, prophylaxis, bitewing x-
rays initial periapical x-ray are listed as covered, out of network providers may bill you for any amount greater 
than what the plan pays. The record shows that one periapical x-ray is covered per calendar year. The record 
shows that the Plan paid for the initial periapical x-ray received on the date of service in this case, thus 
exhausting the frequency limit. Additionally, the adjunctive pre-diagnostic test is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the oral 
exam (D0120), prophylaxis (D1110), periapical x-rays (D0220, D0230 x 2), adjunctive pre-diagnostic testing 
(D0431), and bitewing x-rays (D0274) provided on January 18, 2022 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tuberculosis screening provided to the enrollee on March 25, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no documentation of a medical diagnosis for which this testing may be done, either on 
the claim form or in the available documentation.  
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that the tuberculosis testing as screening for respiratory tuberculosis (Z11.1) 
is not a covered benefit. These services were provided in the absence of signs, symptoms, complaints or 
personal history of a disease or injury. There is no documentation of a medical diagnosis for which this testing 
may be done. The services at issue in this case are not medically reasonable or necessary. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for tuberculosis screening provided to the enrollee on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility visit provided on February 2, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the nursing facility visit. You say that the service was necessary. The Plan denied 
your request. The Plan says the services were provided out-of-network and were not 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 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 the nursing facility visit provided on February 2, 
2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210), implant placement (D6010) 
and implant supported crown (D6066) provided from December 14, 2020, to November 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services were necessary, and you have 
comprehensive dental benefits. 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 the 
surgical extraction (D7210), implant placement (D6010) and implant supported crown (D6066) provided from 
December 14, 2020, to November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam image capture (D0364) and incomplete 
endodontic therapy (D3332) provided on December 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that you feel that it was not your fault that the root 
canal could not be completed, and if a regular root canal is covered then this service should be as well. 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 the cone 
beam image capture (D0364) and incomplete endodontic therapy (D3332) provided on December 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on December 1, 
2021. 
 
You asked the Plan to pay for the services. You say that you want to know why this wasn't covered. The Plan 
denied your request. The Plan says if there is no transport, then there is no benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140) of tooth #'s 27, 28, and 29 
provided on December 10, 2021. 
 
You asked the Plan to pay for the simple extractions. You say that you cannot afford to pay for these services at 
this time. The Plan denied your request. The Plan says these extractions exceed the benefit limit. 
 
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, you are limited to up to 8 simple 
extractions (D7140) every calendar year. The record shows that you received simple extractions (D7140) of 
tooth #'s 23, 24, and 26 on June 4, 2021, simple extractions (D7140) of tooth #'s 18, 20, and 21 on June 25, 
2021, and simple extractions (D7140) of tooth #'s 5 and 22 on December 10, 2021 and your simple extractions 
(D7140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the simple 
extractions (D7140) of tooth #'s 27, 28, and 29 provided on December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
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 your 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation of a recent injury or decline in 
function. The additional therapy services are not an appropriate duration and frequency for treatment of your 
medical condition and therefore are not medically necessary. 
 
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 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the toilet rail provided on November 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the toilet rail. You say that you did not have time to find a network supplier. You 
say this was a safety issue and needed the rail installed. The Plan denied your request. The Plan says the 
provider is out-of-network. 
 
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 the toilet rail provided on November 11, 2021, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided by a participating 
provider on December 1, 2021. 
 
You asked the Plan to pay for gingival irrigation. You say that you were told you were only having a cleaning 
done. You say that you cannot afford this because you are on a budget. The Plan denied your request. The Plan 
says D4921 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) provided by a participating provider on December 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an angioplasty procedure (037G3ZZ) performed September 
10, 2021 to September 13, 2021. 
 
You asked the Plan to pay for the procedure. You say that the service was medically necessary and should be 
covered. The Plan denied your request. The Plan says the claim was not billed with a covered diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 037G3ZZ is not supported in the medical record. Specifically, per Medicare Claims 
Processing Transmittal 2998, page 49, Section C. Billing 161 - Intracranial Percutaneous Transluminal 
Angioplasty (PTA) With Stenting, this service must be billed with diagnosis code 167.2. The claim listed 
diagnosis codes 163.412 and 163.512. Based on this information, we decided that Medicare rules for coverage 
of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for an 
angioplasty procedure (037G3ZZ) performed September 10, 2021 to September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 5, 2021. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item is non-covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
 
 
  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided November 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services provided on November 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 the imaging services provided on November 22, 2021 by an out-of-network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 26, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says providers 
must be eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
physician's services provided on January 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided September 5, 2021. 
 
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says insufficient information was provided to support the claim. 
 
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 radiology services (71045) provided September 5, 2021. have been met. No medical records were provided to support the billed code. Therefore, we 
decided that the Plan does not have to pay for radiology services (71045) provided September 5, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the surgical pathology rendered on September 9, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were not billed correctly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for these services by a contract provider. The file does not show that the plan 
provided notice that these services would not be covered. Under Medicare rules, this means these services is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the surgical pathology 
rendered on September 9, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the partial lower denture (D5214), implant/abutment 
supported removable denture (D6113), and the semi-precision attachment abutment (D6052) provided on 
December 8, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services are necessary. 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 the partial lower denture (D5214), implant/abutment supported removable denture (D6113), and the semi-precision attachment abutment (D6052) 
provided on December 8, 2021.