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

 
We decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on September 
15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are allowed to exams a year. 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 October 2, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam (D0150) provided on 
September 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sacroiliac (SI) joint injection procedure billed with code 
G0260 for July 19, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that G0260 should be reported with an imaging code 
specific to the imaging modality employed. 
 
We looked at the file and Medicare rules. The file shows that procedure code G0260 was not billed with the 
required imaging code specific to the imaging modality employed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the sacroiliac (SI) joint injection procedure billed with code G0260 for July 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CGx Comprehensive Complete Cancer Panel provided 
on November 14, 2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 
81321, 81351, 81209, 81314, 81334, 81345, and 81272. 
 
You asked the Plan to pay for the CGx Comprehensive Complete Cancer Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid 
probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the CGx Comprehensive Complete Cancer Panel provided on November 14, 
2022, and billed with codes 81162, 81201, 81218, 81292, 81295, 81298, 81307, 81317, 81321, 81351, 81209, 
81314, 81334, 81345, and 81272.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network diagnostic mammogram 
and ultrasound provided on June 7, 2023. 
 
You asked the Plan to waive the copayments for a mammogram and ultrasound. You say that this was a 
screening, and you have not had to pay for a mammogram in years. 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 $50 
copayment and a $60 copayment for outpatient diagnostic tests and therapeutic services and supplies.  
You have been asked to pay a total copayment of $110 ($50 copayment for mammogram + $60 copayment for 
an ultrasound = $110 total). You have been asked to pay a $110 copayment for a mammogram and ultrasound. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for an in-network diagnostic mammogram and ultrasound provided on 
June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the topical application of fluoride varnish (D1208) provided on July 27, 
2023. We also decided that the Plan does not have to pay for the dental screening (D0190) provided on July 27, 
2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
denial for payment. The Plan says that you have exhausted the allowable benefit for the topical application of 
fluoride varnish provided in this case. Additionally, the Plan says the dental screening provided is not covered 
under the supplemental dental policy.  
 
We decided that the Plan has to pay for the topical application of fluoride varnish (D1208) provided on 
July 27, 2023. The Plan has stated that you have exhausted the allowable benefit for the topical application of 
fluoride varnish provided in this case as you previously received this service on January 26, 2023. However, 
the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is no evidence provided that demonstrates you previously exhausted the 
allowable benefit for this service. The Plan has not substantiated their denial; therefore, we must find in your 
favor. Therefore, we decided that the Plan has to pay for the topical application of fluoride varnish (D1208) 
provided on July 27, 2023.   
 
We also decided that the Plan does not have to pay for the dental screening (D0190) provided on July 27, 
2023. Specifically, although 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 dental screening (D0190) provided on July 27, 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 the nursing facility care provided on September 03, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that you are requesting 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 the nursing facility care 
provided on September 03, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit for the evaluation provided on 
August 17, 2023. 
 
You asked the Plan to pay for a home or residence visit for the evaluation. You say that this service is 
supported in the records proving medical necessity. 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 a home or residence visit 
for the evaluation provided on August 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on July 05, 
2023. 
 
You asked the Plan to waive the copayment for 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/hospital outpatientfacility. 
 
You have been asked to pay a $350 copayment for outpatient surgery. This item/service falls within the 
outpatient surgery/hospital outpatientfacility 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 outpatient surgery provided on July 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement and trimming provided on July 19, 2023. 
 
You asked the Plan to pay for the debridement and trimming. You say that you are requesting 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 the debridement and 
trimming provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided on August 21, 2023. 
 
You asked the Plan to pay for D7953. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says the denied dental 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 a bone 
replacement graft for ridge preservation (D7953) provided on August 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 30, 2023. 
 
You asked the Plan to pay for the durable medical equipment. You say that you are requesting 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 the durable medical 
equipment provided on April 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0117U) provided on June 30, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the out-of-network service was not pre-authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for lab services (0117U) provided on June 30, 2023, by an out-of-network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elbow orthosis (L3761) provided on June 22, 2023. 
 
You asked the Plan to pay for an elbow orthosis. You say that the item at issue was a necessity for the 
enrollee's care. The Plan denied your request. The Plan says the documentation requirements have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The provided medical records do not address the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for an elbow orthosis (L3761) provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 13, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0260 billed for date of service June 26, 
2023. 
 
You asked the Plan to pay for procedure code G0260. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that code G0260 should be reported with an imaging code specific to the imaging modality 
employed. 
 
We find that code G0260 has not been reported with a corresponding imaging code as required. Based on this 
information, we decided that Medicare rules for coverage of procedure code G0260 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0260 billed for date of service 
June 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 15, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services 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 an office visit provided 
on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on June 27, 2023, by out-of-
network (OON) providers.  
 
You asked the Plan to pay for practitioner services. You say that Please note that all of these physicians are in 
network with your primary health care network 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 June 27, 2023, 
by OON providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for health club membership (S9970) provided on February 
1, 2023. 
 
You asked the Plan to reimburse for health club membership (S9970). You say that you did not know to send in 
one reimbursement form for the whole year. You also say you could do it month by month. The Plan denied 
your request. The Plan says the reimbursement for $49 towards 2023 Wellness Allowance cannot be approved 
as the membership receipt is the same as the one already received and reimbursed for February in the amount 
of $49. 
 
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 up to $150 
per calendar year towards your cost for membership in a qualified health club or fitness facility during the 
calendar year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because the benefit for February 2023 has 
already been exhausted. Therefore, we decided that the Plan does not have to reimburse for health club 
membership (S9970) provided on February 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient mental hospital stay provided 
on March 29, 2023, to March 31, 2023. 
 
You asked the Plan to waive the copayment for the inpatient mental hospital stay. You say that you were 
involuntarily forced to stay. 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 $315 
copayment for inpatient services in a psychiatric hospital.  
You have been asked to pay a $315 copayment for the inpatient mental hospital stay. This item/service falls 
within the inpatient services in a psychiatric 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. You have been asked to pay a total of $630 for the inpatient 
hospital stay ($315 copayment x 2 days = $630). You have not been charged for the day you were discharged. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient mental hospital stay 
provided on March 29, 2023, to March 31, 2023.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a WCE procedure (91110). 
 
You asked the Plan to pre-approve a WCE. You say that the requested service is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says that the requested service is contraindicated in this case. 
 
The Plan follows Medicare rules. The rules say that WCE is covered for the indications listed in the Medicare 
rules section of this letter. 
 
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 WCE. Our reviewer says that a WCE 
is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has ongoing 
iron-deficiency anemia and negative upper endoscopy and colonoscopy. The enrollee meets criteria for 
wireless capsule endoscopy. 
 
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 WCE have been met. Therefore, we decided that the Plan has to pre-approve a 
WCE procedure (91110).  
 
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.