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

 
We decided that the Plan does not have to waive the deductible for the specialist office visit and nasal tear duct 
probe provided on December 16, 2022. 
 
You asked the Plan to waive the deductible for the specialist office visit and nasal tear duct probe. You say that 
this was not a surgery The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to out-of-network specialist office 
visits. Your contract with the Plan also says that you must pay 50% coinsurance after meeting the deductible for out-of-network specialist office visits. Your contract with the Plan also says that you must pay 50% 
coinsurance after meeting the deductible for out-of-network outpatient surgery.   
 
You have been asked to pay $197.64 towards the deductible for the specialist office visit. This item/service 
falls within the physician/practitioner services benefit category. You have also been asked to pay $288.98 
towards the deductible for the nasal tear duct probe. According to Medicare the nasal tear duct probe (code 
68810) is considered outpatient surgery. This item/service falls within the outpatient surgery benefit category. 
You have been asked to pay a total of $486.62 towards the deductible ($197.64 deductible + $288.98 
deductible = $486.62). 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible 
which applies to out-of-network specialist office visits and out-of-network outpatient surgery. This cost sharing 
is a contractual obligation that had not been met at the time the specialist office visit and nasal tear duct probe 
were received on December 16, 2022. Therefore, we decided that the Plan does not have to waive the 
deductible for the specialist office visit and nasal tear duct probe provided on December 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (code 87086) billed for date of 
service December 1, 2022. 
 
You asked the Plan to pay for code 87086. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this service was billed with a non-covered diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers bacterial urine culture 
testing when billed with a covered diagnosis. The only diagnosis you billed on this claim is N32.81 (overactive 
bladder).  This diagnosis is not listed in the above-referenced rule in the ICD-10-CM Codes Covered by 
Medicare Program section. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 87086 have not been met. Therefore, we decided that the Plan does not have to pay for the 
bacterial urine culture (code 87086) billed for date of service December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5261) rendered by the out-of-network 
(OON) provider on October 27, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items at issue are not payable as they 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 items at issue in this appeal. The Plan did not pre-approve the items at issue.   
 
We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan 
does not have to pay for the hearing aids (V5261) rendered by the out-of-network (OON) provider on  
October 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the benralizumab injection and drug 
administration provided on January 30, 2023. 
 
You asked the Plan to waive the coinsurance for the drug injection and drug administration. You say that you 
were told this would be covered, and do not feel it was. 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 20% 
coinsurance for in-network Medicare Part B drugs and drug administration.  
 
You have been asked to pay $1,009.50, which is 20% coinsurance of the allowed amount for the drug injection 
($5,047.50 allowed amount x 20% coinsurance = $1,009.50). You have also been asked to pay $2.72, which is 20% coinsurance of the allowed amount for the drug administration ($13.59 allowed amount x 20% 
coinsurance = $2.72). These items/services fall within the in-network Medicare Part B drugs benefit category. 
You have been asked to pay a total of $1,012.22 ($1,009.50 coinsurance + $2.72 coinsurance = $1,012.22). 
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 the benralizumab injection and drug administration 
provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on October 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 the dental 
services on October 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2391 and D2392) provided on 
December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you purchased supplementary benefits so all the 
services should be covered. The Plan denied your request. The Plan says the denial of payment for these 
services is correct because the resin-based composites are not covered by the Plan. Also, the enrollee added 
supplemental dental to his policy effective on January 1, 2023. 
 
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 under the preventative dental benefits that were in effect during the 
date of service. Therefore, we decided that the Plan does not have to pay for the resin-based composites 
(D2391 and D2392) provided on December 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from October 1, 2022, 
to October 31, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were told the member's SNF visit 
was going to be fully covered. 
 The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment per day for days 1 to 20, a $150 copayment per day for days 21 to 45, and $0 
copayment per day for days 46 to 100 for SNF care.  
 The enrollee has been asked to pay a $1,950 copayment for a SNF stay ($150 per day x 13 days = $1,950). This 
item/service falls within the SNF care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SNF stay provided from October 1, 2022, to October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on 
September 15, 2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for outpatient surgery/outpatient hospital. 
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery/outpatient hospital 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 outpatient surgery provided on September 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) provided on January 5, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you do not agree with the denial of the service 
you received. 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 Plan paid 
$192 for services on January 4, 2023, $626 for services on January 5, 2023, and $182 for services on January 9, 
2023 ($192 + $626 + $182 = $1,000), which is the annual maximum of $1,000. The record show your benefit 
for the requested item or service was exhausted. Therefore, we decided that the Plan does not have to pay for 
crown - porcelain/ceramic (D2740) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam (92012) provided on January 10, 2023. 
 
You asked the Plan to pay for the eye exam. You say that you are allowed one routine eye exam per year. You 
also say that the exam was denied even though your prescription eyeglasses claim was approved and paid. The 
Plan denied your request. The Plan says that this charge cannot be paid because you received the service from a 
provider who chose not to receive Medicare funds. The Plan also says this means they are on the Medicare opt 
out list. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye exams once every year. 
 
We looked at the file and the Plan's rules. Specifically, the documentation provided does not show that you 
have exhausted your eye exam benefit for the 2023 Plan year. The 2023 Evidence of Coverage also does not 
indicate that non-Medicare covered routine vision exams are non-covered if they are rendered by a provider 
who has opted out of Medicare. Based on this information, we decided that the Plan's rules for coverage of the 
eye exam have been met. Therefore, we decided that the Plan has to pay for the eye exam (92012) provided on 
January 10, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided from July 
19, 2022, to July 26, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that there is reported pain at initiation 
of movement, and extreme limits of range. The Plan denied your request. The Plan says this is not covered by 
Medicare. 
 
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 from July 19, 2022, to July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 04, 
2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on January 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99212) and the x-ray exam of the lumbar 
spine (72100) provided on January 5, 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 these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99212) and the x-ray exam of the lumbar spine (72100) 
provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service 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 the dental 
services on January 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions-four or 
more teeth or tooth spaces, per quadrant (D7320) provided on January 12, 2023. 
 
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 this service 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 service provided is not among 
those covered under this benefit.  
  
 
 
Therefore, we decided that the Plan does not have to pay for the alveoloplasty not in conjunction with 
extractions-four or more teeth or tooth spaces, per quadrant (D7320) provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each romiplostim injection provided on 
January 03, 2023, to January 20, 2023. 
 
You asked the Plan to waive the coinsurance for each romiplostim injection. You say that you do not feel this is 
the correct number of doses and visits. 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 20% 
coinsurance for Medicare Part B drugs. 
 
You have been asked to pay 20% coinsurance for each romiplostim injection. This item/service falls within the 
Medicare Part B drugs 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 these claims were approved and you are responsible for the cost share 
amount. Therefore, we decided that the Plan does not have to waive the coinsurance for each romiplostim 
injection provided on January 03, 2023, to January 20, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 17, 
2023. 
 You asked the Plan to pay for procedure code 76770. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 76770 is bundled into payment for code 
76705. 
 
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, we have confirmed that code 76770 
is a column II code to column I code 76705. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service January 17, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for buccal/labial frenectomy (frenulectomy) (D7961) provided 
on December 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you had the service because it was necessary to 
maintain your dental condition; therefore, this service should be covered. The Plan denied your request. The 
Plan says this service is not covered under your 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. Buccal/labial frenectomy 
(frenulectomy) (D7961) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7961 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for buccal/labial 
frenectomy (frenulectomy) (D7961) provided on December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure code 99223) rendered on September 
19, 2022. 
 
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 the provider did not bill as required by Medicare coding regulations. 
 
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 99223 is not supported in the medical record. Specifically, this code was billed on the same day at CPT 99152. CPT 99152 has a global surgery period of zero days. Therefore, CPT 99223 should 
not have been reported separately. 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 hospital care 
(procedure code 99223) rendered on September 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from January 1, 
2022, to December 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that the letter from your physician says you 
need someone to come into the home to help with dressing, bathing, and transfers. The Plan denied your 
request. The Plan says the requested payment for services is denied because they were custodial in nature. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home 
health care services provided from January 1, 2022, to December 31, 2022.