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

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation - new or established 
patient (D0150), intraoral  comprehensive series of radiographic images (D0210), and prophylaxis - adult 
(D1110) provided on May 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that supposedly since you were advised the 
services were covered, this should be covered in full and according to this denial of payment it's going to be 
covered partially. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation - new or 
established patient (D0150), intraoral  comprehensive series of radiographic images (D0210), and prophylaxis 
- adult (D1110) provided on May 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 27486 and 27301 billed for date of service 
March 31, 2023. 
 You asked the Plan to pay for procedure codes 27486 and 27301. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says payment for code 27301 is bundled into payment for code 
27486. 
 
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 27486 is not supported 
in the medical record. Specifically, the appropriate modifier is missing to support the revision of total knee 
arthroplasty with replacement of only the tibial polyethylene liner. Therefore, code 27486 is not supported. In 
this case, we have confirmed that code 27301 is a column II code to column I code 27486. 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 codes 27486 
and 27301 billed for date of service March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the add tooth to existing partial denture (D5650) and add 
clasp to existing partial denture - per tooth (D5660) provided on December 14, 2020, and December 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that you had not received any documentation or 
denial until this year, 2023 of any procedures done in or by this office. The Plan denied your request. The Plan 
says procedures, D5650 and D5660 do not appear on the medical benefits chart and are therefore not covered. 
 
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 add 
tooth to existing partial denture (D5650) and add clasp to existing partial denture - per tooth (D5660) provided 
on December 14, 2020, and December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80307, 83789, and G0480 provided on June 
19, 2023. 
 
You asked the Plan to pay for procedure codes 80307, 83789, and G0480. You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
supported.  
The Plan must follow Medicare rules. Medicare rules say while a physician order is not required to be signed, 
the physician must clearly document, in the medical record, the intent that the test be performed. 
 
We find that CPT codes 80307, 83789, and G0483 are not supported in the medical record. Specifically, 
medical records submitted do not include an order that specifically list what test(s) are to be performed in the 
custom panel. Based on this information, we decided that Medicare rules for coverage of procedure codes 
80307, 83789, and G0483 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 80307, 83789, and G0480 provided on June 19, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 12, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
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 April 10, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on April 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 20, 2023, to April 
18, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you are requesting a reconsideration of the 
denied claim. 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 skilled nursing facility 
provided on March 20, 2023, to April 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
services received on May 6, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport services. You say that 
you should not be liable for the charges since you were not the one who requested the ambulance service. The 
Plan denied your request. The Plan says ambulance response and treatment with no transport is not a payable 
service. 
 
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 May 6, 2023. 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 the ambulance response and treatment with no 
transport services received on May 6, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on June 8, 2023, to 
June 9, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that the medication should be covered by 
the insurance. The Plan denied your request. The Plan says that self-administered drugs do not fall under 
Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on June 8, 2023, to June 9, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on May 10, 
2023, to June 02, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you were being charged 
the same amount for something in the same hospital. 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 Inpatient hospital care.  
You have been asked to pay a $325 copayment for inpatient hospital stay. This item/service falls within the 
Inpatient hospital care 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 a total of $1,950 for the inpatient hospital stay ($325 
copayment x 6 days = $1,950). You have not been charged for any inpatient days after day six. Therefore, we 
decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on May 10, 
2023, to June 02, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for you. The Plan 
denied your request. The Plan says your records do not show that you need to be seen by a rehabilitation doctor 
three times per week or that you need an intensive team for your care.  The Plan says services may be provided 
at a lower level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on August 
04, 2023. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that you are wondering why 
your copayment is different from the rest of the Plan. 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 $40 
copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for occupational therapy. This item/service falls within the Outpatient rehabilitation 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 a $40 copayment for an OON occupational therapy 
service. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy 
provided on August 04, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) provided on April 04, 2023. 
 
You asked the Plan to pay for skilled nursing facility (SNF). You say that you are requesting a reconsideration 
of the denied claim. 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 skilled nursing facility 
(SNF) provided on April 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130) provided on June 
1, 2023. 
 
You asked the Plan to pay for the denture. You say that the service was not immediate. You also say that it was 
almost a month before you had teeth pulled and a partial put in your upper mouth. The Plan denied your 
request. The Plan says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
immediate denture - maxillary (D5130) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve a genicular nerve block. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered 
investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to 
any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not 
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block 
of the left knee is 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 a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block (64454).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on March 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 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 March 7, 2023. 
Therefore, we decided that the Plan does not have to pay for additional intraoral x-rays (D0230) provided on 
March 7, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen and oxygen supplies (A0422) provided on 
February 1, 2023. 
 
You asked the Plan to pay for the ambulance supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the cost of these ambulance supplies is 
included in the ambulance fee schedule payment. 
 The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for the oxygen and oxygen supplies (A0422) provided on 
February 1, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G2078 provided on June 29, 2023. 
 
You asked the Plan to pay for procedure code G2078. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services billed exceed the benefit limit. 
 
The Plan must follow Medicare rules. Medicare rules say that G2078 cannot be billed more than three times in 
one month. 
 
We looked at the file and Medicare rules. Review of the file shows that procedure code G2078 was billed with 
6 units total for the month of June. Three of these units were paid for the June 1, 2023, date of service. Based on this information, we decided that Medicare rules for coverage of the take-home supply of methadone have 
not been met for the June 29, 2023, date of service. Therefore, we decided that the Plan does not have to pay 
for procedure code G2078 provided on June 29, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 01, 2023, to June 30, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting a reconsideration of the denied 
claims. 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 physical therapy 
provided on June 01, 2023, to June 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a saddle bag and a rear basket. 
 
You asked the Plan to pre-approve a saddle bag and a rear basket. You say that the items are necessary. The 
Plan denied your request. The Plan says the requested items are not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a saddle bag and a rear basket.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft (D7286). 
 
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 the rendering 
provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an incisional biopsy of oral tissue-soft 
(D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gym membership provided on January 1, 2022. 
 
You asked the Plan to pre-approve a gym membership. You say that due to sickness in your family, you lost 
time to submit the request within the timeframe. The Plan denied your request. The Plan says you submitted a 
reimbursement for a 2022 wellness allowance after the March 31st deadline. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when the request for reimbursement has been received on March 31st of the following year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the reimbursement request was 
received was received on May 5, 2023, which is after the March 31st deadline. Therefore, we decided that the 
Plan does not have to pre-approve a gym membership provided on January 1, 2022.