Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services provided on July 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on August 21, 
2023. 
 
You asked the Plan to pay for anti-reflective coating. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this service is not covered under your contract under any normal 
circumstances. 
 
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 these services when the lenses are standard lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that covered eyeglasses after cataract surgery 
includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not 
limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). Based on this information, we 
decided that the Plan's rules for coverage of anti-reflective coating have not been met. Therefore, we decided 
that the Plan does not have to pay for anti-reflective coating (V2750) provided on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 26, 2023, to August 16, 
2023. 
 
You asked the Plan to pay for laboratory services. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 services provided on July 26, 2023, to August 16, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the set-up portable x-ray equipment (Q0092) provided on 
June 21, 2023. 
 
You asked the Plan to pay for the equipment set-up. You say that the service was billed correctly and should be 
paid. The Plan denied your request. The Plan says no medical records were received to verify Current 
Procedural Terminology (CPT) code Q0092.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the equipment set-up have been met. 
The provider did not provide any medical records to support the reason for the appeal. The Plan provided 
evidence that they have tried to contact the provider multiple times to request medical records but were 
unsuccessful. Therefore, we decided that the Plan does not have to pay for the set-up portable x-ray equipment 
(Q0092) provided on June 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services provided on October 03, 2023. 
 
You asked the Plan to pay for ophthalmology services. You say that the services do not require prior 
authorization 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 ophthalmology services provided on October 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service October 28, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you would like the Plan to reconsider their 
denial of payment. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service October 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and an 
anterior apicoectomy (D3410) provided on October 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that these were dental emergency procedures due to 
an infection. 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 items or services was exhausted on dates of service February 16, 2023, 
August 30, 2023, and September 25, 2023. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and an anterior apicoectomy (D3410) provided on October 5, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87635 billed for date of service July 15, 
2023. 
 
You asked the Plan to pay for procedure code 87635. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the provided records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 87635 is not supported. Specifically, a physician order for the services at issue has not 
been provided for review. Based on this information, we decided that Medicare rules for coverage of procedure 
code 87635 have not been met.  
  Therefore, we decided that the Plan does not have to pay for procedure code 87635 billed for date of service 
July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit received on April 18, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the annual wellness visit. You say that you were told that the physician was in 
your network. The Plan denied your request. The Plan says the services do not meet the criteria for approval. 
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 
the annual wellness visit received on April 18, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on July 27, 2023. 
 
You asked the Plan to pay for the consultation (D9310). You say that you were never told that the second 
opinion was not a covered benefit. 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 consultation (D9310) is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation 
(D9310) provided on July 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management (E&M) services described 
by codes 99233 performed on June 23, 2023, and 99232 performed on June 24, 2023, and June 25, 2023. 
 
You asked the Plan to pay for the E&M services. You say that the E&M services should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says the E&M 
services are denied because they are not supported in the documentation.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. In this case, we confirmed that there is no documentation of E&M 
services in the record for dates of service June 23, 2023, June 24, 2023, or June 25, 2023. The records consist 
only of an E&M service performed on June 20, 2023. The case file contains evidence that the Plan requested 
records for the dates of service in question on multiple occasions. Based on this information, we decided that 
there is insufficient information in the record to determine if Medicare rules for coverage of the E&M services 
have been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management 
(E&M) services described by codes 99233 performed on June 23, 2023, and 99232 performed on June 24, 
2023, and June 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and ear wax removal. provided on August 14, 
2023. 
 
You asked the Plan to pay for an office visit and ear wax removal.. You say that the service was medically 
necessary. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 and ear wax removal. provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
June 20, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service May 30, 2023. 
  
 
Specifically, the Plans contract states that a re-cement or re-bond of a crown is covered once every 24 months. 
You previously received this service on May 30, 2023, less than 24 months prior, which was paid for by the 
Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan 
does not have to pay for the re-cement or re-bond of a crown (D2920) provided on June 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 28, 
2023, to September 11, 2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you should not have to pay this 
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 $50 
copayment for physician/practitioner services. 
 
You have been asked to pay a $50 copayment for outpatient surgery. 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. You have been asked to pay a $50 copayment for surgery services provided by a 
specialist. Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery 
provided on August 28, 2023, to September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210) provided on 
August 29, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that the tooth removal 
needed to be approved separately. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210) provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft (D7286) provided on 
September 19, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service September 19, 2023.  
  
Specifically, the Plans contract states that one incisional biopsy of oral tissue is covered per day. On this day, 
you received two incisional biopsies of oral tissue, of which one biopsy was paid for by the Plan. Therefore, 
you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to 
pay for the incisional biopsy of oral tissue-soft (D7286) provided on September 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator purchased on August 21, 2023. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you have been using an Inogen for years. 
You say that your first one stopped working so you had to get a new on, which you use several times a day. 
You say that your oxygen level often drops as low as 81% when you are moving around your apartment. You 
say that you use an oximeter to monitor yourself. The Plan denied your request. The Plan says the purchased 
oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
concentrator purchased on August 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on August 31, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
Per review of the DEX Diagnostic Exchange, the Tempu xF test was reviewed through the MolDX process and 
was found to not meet Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for 
the Tempus xF testing (81455) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5214) provided on August 17, 2023. 
 
You asked the Plan to pay for hearing aids. You say that the company you purchased the aids from did not 
inform that this was to be in-network. The Plan denied your request. The Plan says this service is not covered 
out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids (V5214) provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of soft oral tissue (D7286) provided on September 
12, 2022. 
 
You asked the Plan to pay for the biopsy of soft oral tissue (D7286). You say that it is unclear if this service 
should have been covered under your medical or dental benefits. 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 biopsy of soft oral tissue (D7286) 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
biopsy of soft oral tissue (D7286) provided on September 12, 2022.