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

 
We decided that the Plan does not have to pay for the dental services (D2970 x 3) and the unspecified 
preventive procedure, by report (D1999) provided on June 21, 2023. 
 
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 unspecified preventive procedure provided 
is not covered under the supplemental dental policy. Additionally, code D2970 submitted for consideration of 
payment for dental services provided is not applicable for dental coverage.  
 
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 unspecified preventive procedure 
provided is not among those covered under this benefit. Additionally, current procedural terminology (CPT) 
code D2970 submitted for payment of dental services provided is invalid. Therefore, we decided that the Plan 
does not have to pay for the dental services (D2970 x 3) and the unspecified preventive procedure, by report 
(D1999) provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on August 22, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for OON practitioner services. You say that this was to be an office visit to establish 
a new primary care provider. The Plan denied your request. The Plan says that their original decision to deny 
payment was correct. 
 
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 practitioner services provided on August 22, 2023, 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (G0482 and 80307) provided June 14, 
2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 laboratory services have been met. 
Code G0482 is not supported because the medical records provided did not include laboratory results for the 
code billed. Code 80307 remains not supported because the medical records provided do not include laboratory 
results for the code billed. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(G0482 and 80307) provided June 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve intracept intraosseous nerve ablation system. You say that you are 
requesting reconsideration for the denied claim. The Plan denied your request. The Plan says the requested 
service does not meet the requirements for approval. 
 
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 intracept intraosseous nerve ablation 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no magnetic resonance imaging (MRI) showing 
only modic changes without facet degenerative joint disease (DJD) or stenosis. The cause of pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intracept intraosseous nerve ablation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve intracept intraosseous nerve ablation system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy 
(endoscopy) (43239) provided on August 8, 2023. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that you were not informed ahead of 
time how much this procedure would cost, and you feel you should not have to pay such a large amount. 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 $270 
copay per day for other outpatient procedures and services, including, but not limited to therapeutic endoscopy 
under the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers benefit category. 
 
You have been asked to pay a $270 copay per day for the endoscopy. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the 
esophagogastroduodenoscopy (endoscopy) (43239) provided on August 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97110, 97112, 97116, 97750) provided on 
April 20, 2022 to May 11, 2022. 
 
You asked the Plan to pay for the therapy services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 codes 97110, 97112, 97116, & 97750 are not supported in the medical record. Specifically, 
the records show these services were provided in the home setting. There is a more appropriate code for these 
services when performed in the home setting (G0151). Based on this information, we decided that Medicare 
rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for therapy services (97110, 97112, 97116, 97750) provided on April 20, 2022 to May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $2,000 annual maximum 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral evaluation and bitewing x-rays (D0274, D0120) 
provided on July 6, 2023. 
 
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 the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for periodic oral evaluation and bitewing x-rays (D0274, D0120) provided on July 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have only seen one other dentist this year 
and that was in January. The Plan denied your request. The Plan says your benefit 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 January 23, 2023, and 
August 7, 2023. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150) provided on August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
July 13, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you already paid $45. 
You also say you would like the Plan to arrange for the $20 charge to be dropped or paid for by the Plan so the 
provider stops billing you. 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 $65 
copayment for out-of-network Medicare-covered examination. 
 
You have been asked to pay a $65 copayment for a medical eye examination. This item/service falls within the 
out-of-network Medicare-covered examination 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 medical eye examination provided on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the intraoral-periapical first radiographic image (D0220), intraoral-
periapical additional radiographic image (D0230), endodontic therapy, of a molar tooth (excluding final 
restoration) (D3330), and the core buildup, including any pins when required (D2950) provided on May 18, 
2023.  
 
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 that the services are not payable as they were 
rendered by an out-of-network provider.  
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The plan contract says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan did not have contract providers 
located within reasonable distance and travel time from your home who could have provided these services. 
Under Medicare rules, this means that contract providers were not accessible to you. Therefore, we decided that 
the Plan has to pay for the intraoral-periapical first radiographic image (D0220), intraoral-periapical additional 
radiographic image (D0230), endodontic therapy, of a molar tooth (excluding final restoration) (D3330), and 
the core buildup, including any pins when required (D2950) provided on May 18, 2023.   
 
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 hospital inpatient or observation discharge day management; 
more than 30 minutes on the date of the encounter (99239) provided August 16, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 service have been met.  The 
records submitted included a Discharge Summary with a date of service August 15, 2023. The appellant did not 
submit any documentation of services on August 16, 2023. Only one hospital discharge day management 
service is payable per patient per hospital stay. There is no documentation of these services being performed on 
this date of service. Therefore, we decided that the Plan does not have to pay for hospital inpatient or 
observation discharge day management; more than 30 minutes on the date of the encounter (99239) provided 
August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 25, 2023, by an out-
of-network (OON) provider.  
 You asked the Plan to pay for practitioner services. You say that you are appealing the denial, based on medical 
necessity. The Plan denied your request. The Plan says that their original decision to deny payment for service 
was correct. 
 
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 practitioner services provided on April 25, 2023, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 24, 2023. 
 
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 benefit 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 September 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for palliative (emergency) treatment of dental pain (D9110) 
provided on September 7, 2023. 
 
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 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 palliative 
(emergency) treatment of dental pain (D9110) provided on September 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and a binocular 
microscopy provided on July l1, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit and a binocular microscopy. You say 
that you do not believe you should be charged since this was a part of your annual hearing examination, which 
is $0 per year. 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 $30 
copayment for other diagnostic tests and a $40 copayment for a consultation, diagnosis, and treatment by a 
specialist.  
 You have been asked to pay $24.73, which is less than the $30 copayment for a binocular microscopy. A 
binocular microscopy falls within the other diagnostic tests benefit category. You have also been asked to paya 
$40 copayment for a specialist office visit. This item/service falls within the consultation, diagnosis, and 
treatment by a 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. The record shows that this was a specialist office visit and a diagnostic test. Therefore, we 
decided that the Plan does not have to waive the copayment for a specialist office visit and a binocular 
microscopy provided on July l1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4550 billed for date of service July 11, 
2023. 
 
You asked the Plan to pay for procedure code A4550. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code A4550 is considered bundled and 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 procedure code. 
 
We find that procedure code A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4550 have not been met. Furthermore, CPT code A4402 has a status indicator of 
P on the Physician Fee Schedule. This means there are no RVUs, and no payment amounts for these services. 
No separate payment is made for them under the fee schedule. If the item or service is covered as incident to a 
physician service and is provided on the same day as a physician service, payment for it is bundled into the 
payment for the physician service to which it is incident (an example is an elastic bandage furnished by a 
physician incident to a physician service). If the item or service is covered as other than incident to a physician 
service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under the other 
payment provision of the Act. Therefore, we decided that the Plan does not have to pay for procedure code 
A4550 billed for date of service July 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.