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

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), intraoral - periapical first radiographic image (D0220), and each additional radiograph image (D0230) 
provided on January 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that your lower teeth are decaying since the gold 
caps fell out and is causing your pain. You also say that this should be covered because you took extra 
insurance and need to have your lower teeth extracted and be fitted for new dentures as well. The Plan denied 
your request. The Plan says your benefit for the requested services $1,000 dollar limit was met. 
 
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  services was exhausted on date of service January 6, 2023. The Plan paid 
$1,000 for the denture services rendered on the same date of service. Therefore, we decided that the Plan does 
not have to pay for a comprehensive oral evaluation - new or established patient (D0150), intraoral - periapical 
first radiographic image (D0220), and each additional radiograph image (D0230) provided on January 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93926 billed for date of service July 14, 
2022. 
 
You asked the Plan to pay for procedure code 93926. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93926 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93926 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93926 billed for date of service July 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 15, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. 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 laboratory testing 
provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit with a laboratory draw 
provided on May 24, 2022. 
 
You asked the Plan to waive the copayment for an office visit with a laboratory draw. You say that you should 
not have to pay this copayment for labs. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an office visit with a laboratory draw. This item/service falls 
within the physician/practitioner services, including doctors office visits 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 office visit with a laboratory draw provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on August 01, 2022. 
 
You asked the Plan to pay for wound care. You say that you are requesting the submitted documentation be 
reviewed. 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 wound care provided on 
August 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the drug injection and specialist office visits 
provided from November 22, 2021, to December 23, 2021 
 
You asked the Plan to waive the cost share for the drug injection and specialist office visits. You say that you 
had already met your out-of-pocket maximum. 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. Your contract with the Plan also clearly says that you must pay a $10 
copayment for each specialist office visit.  
 
The records show your out-of-pocket maximum was processed correctly. You have been asked to pay 20% 
coinsurance for the drug injection. This item/service falls within the Medicare Part B drugs benefit category. 
You have also been asked to pay a $10 copayment for each specialist office visit. This item/service falls within 
the physician/practitioner services 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 cost share for the 
drug injection and specialist office visits provided from November 22, 2021, to December 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you did not believe your copayment 
would be this high. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for colonoscopy. This item/service falls within the outpatient 
hospital services 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 colonoscopy 
provided on January 30, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that long-term acute care is the right level of 
care for the member. The Plan denied your request. The Plan says the LTACH services requested do not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. All medically 
necessary care is being provided in the current acute care setting.  The health plan has approved ongoing care 
in the current acute care setting. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 8, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 8, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 26, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service July 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the laboratory services provided on March 
12, 2021. 
 
You asked the Plan to waive the cost share for the lab services. You say that you did not know there would be 
additional charges and did not know the lab being used was out-of-network. 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 $250 out-of-network deductible which applies to out-of-network 
laboratory services. Your contract with the Plan also says that you must pay 20% coinsurance after meeting the 
deductible for out-of-network laboratory services. 
 
You have been asked to pay $250 towards your out-of-network deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 out-of-network deductible which applies to out-
of-network laboratory services. This cost sharing is a contractual obligation that had not been met at the time 
the lab services were received on March 12, 2021.  
 
The remaining amount after applying the deductible is $30 ($280 allowed amount - $250 deductible = $30). 
You have also been asked to pay $6, which is 20% coinsurance of the remaining amount for the lab services 
after applying the deductible ($30 remaining amount x 20% coinsurance = $6). You have been asked to pay a 
total of $256 ($250 deductible + $6 coinsurance = $256). 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 cost share 
for the laboratory services provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on November 04, 
2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you believe the services should be 
covered because. 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 $10 
copayment for physician/practitoner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for office visit. This item/service falls within the 
physician/practitoner services, including doctors office visits 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 office visit provided on November 04, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 8, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you attempted to file the NOA in 
a timely fashion.  In addition, you stated that you believe the Plan was not enforcing the NOA timely filing 
requirement at the time of the services in dispute. The Plan denied your request. The Plan says the claim has 
not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 8, 2022, to April 
6, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service January 5, 
2023. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service January 5, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA, and you believe that the Plan wasn't enforcing the timely filing rule for NOAs at the time of submission. 
The Plan denied your request. The Plan says the claim has not been billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 7, 2022, to 
February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for each radiation therapy service provided 
on October 01, 2022, to November 30, 2022. 
 
You asked the Plan to reduce the coinsurance for each radiation therapy service. You say that you need 
assistance paying for these bills. 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 outpatient radiation therapy. 
 
You have been asked to pay 20% coinsurance for each radiation therapy service. This item/service falls within 
the in-network outpatient radiation therapy 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 reduce the coinsurance 
for each radiation therapy service provided on October 01, 2022, to November 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network intraarticular injection 
procedure provided on December 09, 2022. 
 
You asked the Plan to waive the copayment for an in-network intraarticular injection procedure. You say that 
you are on a fixed income, and this is price gouging. 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 $275 
copayment for outpatient hospital services. 
 
You have been asked to pay a $275 copayment for an in-network intraarticular injection procedure. This 
item/service falls within the outpatient hospital services 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. You have been asked to pay the allowed amount of $256.87 
which is less than the $275 copayment for an intraarticular injection procedure. Therefore, we decided that the 
Plan does not have to waive the copayment for an in-network intraarticular injection procedure provided on 
December 09, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74220 billed for date of service October 18, 
2022. 
 
You asked the Plan to pay for procedure code 74220. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 74220 is bundled into payment for code 
74230. 
 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 74220 
is a column II code to column I code 74230 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 74220 billed for date of service October 18, 2022.