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

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on January 
27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to a new provider who said they could 
not use the x-ray you previously had. You say that you should not have to pay for this x-ray. 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. This benefit includes the 
requested panoramic radiographic image (D0330) but is limited to one per 3 plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered panoramic radiographic image (D0330) on August 9, 2022. Therefore, this 
benefit was exhausted as of January 27, 2023. Therefore, we decided that the Plan does not have to pay for 
panoramic radiographic image (D0330) provided on January 27, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69990 billed for date of service October 4, 
2022. 
 You asked the Plan to pay for procedure code 69990. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 69990 is bundled into 
payment for code 61781. 
 
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 69990 
is a column II code to column I code 61781. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.  Therefore, we 
decided that the Plan does not have to pay for procedure code 69990 billed for date of service October 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the colonoscopy and biopsy provided on 
January 5, 2022. 
 
You asked the Plan to waive the cost share for the colonoscopy and biopsy. You say that the service is 
considered out-of-network and was approved by 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. Your 
contract with the Plan says that there is a $1,500 deductible which applies to the out-of-network colonoscopy 
and biopsy. Your contract with the Plan also says that there is a 40% coinsurance once the deductible has been 
met for out-of-network surgery services provided at an outpatient hospital. 
 
 You have been asked to pay $1,151.83, which satisfies your deductible for the colonoscopy. The remaining 
allowed amount is $169.54 ($1,324.37 allowed amount - $1,151.83 deductible = $169.54 remaining allowed 
amount). The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 
deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities. This 
cost sharing is a contractual obligation that had not been met at the time the colonoscopy and biopsy was 
received on January 5, 2022. 
 
You have also been asked to pay $67.82, which is 40% coinsurance of the remaining allowed amount for the 
colonoscopy ($169.54 remaining allowed amount x 40% = $67.82). You have also been asked to pay $264.28, 
which is 20% coinsurance of the allowed amount for the biopsy ($660.69 allowed amount x 40% = $264.28). 
You have been asked to pay a total of $1,483.93 for the colonoscopy and the biopsy ($1,151.83 deductible + 
$67.82 coinsurance + $264.28 coinsurance = $1,483.93). The items or services you asked the Plan to waive the 
cost share for fall within the outpatient surgery, including services provided at hospital outpatient facilities 
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 colonoscopy and biopsy 
provided on January 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in network diagnostic mammogram and 
ultrasound provided on December 23, 2022. 
 
You asked the Plan to waive the copayment for an in network diagnostic mammogram and ultrasound. You say 
that this was a follow up to a screening. You were not aware there would be a copay for this visit and thought it 
was part of the screening. 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 $90 
copayment for basic radiological services. 
 
You have been asked to pay a $90 copayment for an in network diagnostic mammogram and ultrasound. This 
item/service falls within the basic radiological 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 an in network diagnostic mammogram and ultrasound provided on December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for mandibular partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided on July 13, 2022. 
 
You asked the Plan to pay more for the dental services. You say that there was a predetermination approved for 
$0 member responsibility, so you should have no responsibility. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
$105 for date of service June 2, 2022, and $1,895 for date of service July 13, 2022, which is the annual 
maximum of $2,000. The record show your benefit for the requested service was exhausted on July 13, 2022.  
Therefore, we decided that the Plan does not have to pay more for mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214) provided 
on July 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on January 03, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
January 03, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on September 
22, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). 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 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 magnetic resonance 
imaging (MRI) provided on September 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on July 13, 2022. 
 You asked the Plan to pay for physical therapy services. You say that the enrollee's discharge date is July 8, 
2022. 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 July 8, 2022. The services in question were provided before 
the end of that month.  Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided on July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would be able to participate in all 
required hours of therapy to meet inpatient rehab criteria.  The Plan denied your request. The Plan says an IRF 
admission is not medically necessary.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal care services provided from January 03, 2023, to 
January 31, 2023. 
 
You asked the Plan to pay for personal care services. You say that you would like this service covered by your 
insurance. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature.  Therefore, we decided that the Plan does not have to pay for personal care 
services provided from January 03, 2023, to January 31, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a PT visit provided on December 21, 
2022. 
 
You asked the Plan to waive the coinsurance for a PT visit. You say that your out-of-pocket maximum was 
met, and you should not owe anything. 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 15% 
coinsurance for each Medicare-covered physical therapy and speech language therapy visit.  
 
You have been asked to pay $1.27 coinsurance for a PT visit. The amount applied is less than the standard 
coinsurance because the maximum out-of-pocket was met with the processing of this claim. 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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a PT visit provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-hard (bone, tooth) 
(D7285), the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), and 
the limited oral evaluation-problem focused (D0140) provided on September 22, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are not covered by 
Medicare.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral 
tissue-hard (bone, tooth) (D7285), the extraction, of an erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210), and the limited oral evaluation-problem focused (D0140) provided on  
September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration and the application of a 
desensitizing medicament (D4266, D9910) provided on January 4, 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 the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 guided 
tissue regeneration and the application of a desensitizing medicament (D4266, D9910) provided on January 4, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305, 88341, 88342, & 88360 billed for 
date of service August 2, 2022. 
 You asked the Plan to pay for procedure code(s) 88305, 88341, 88342, & 88360. You say that these services 
were medically necessary. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305, 88341, 88342, 
& 88360. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305, 
88341, 88342, & 88360. Based on this information, we decided that Medicare rules for coverage of procedure 
code 88305, 88341, 88342, & 88360 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 88305, 88341, 88342, & 88360 billed for date of service August 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
February 16, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told you would 
not be charged. 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 $45 
copayment for you were told you would not be charged.. 
 
You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
you were told you would not be charged. 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 the specialist office visit provided on February 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), periodic oral evaluation - established patient (D0274), and prophylaxis - adult (D1110) provided on 
January 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that preventive dental care is covered with $0 
copayment as shown in the summary of benefits document for 2023. You also say that these services were 
routine preventive dental care and should be fully covered with a $0 copayment. 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 a periodic oral evaluation - established 
patient (D0120), periodic oral evaluation - established patient (D0274), and prophylaxis - adult (D1110) 
provided on January 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on January 30, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you were not 
aware the copayments were so 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 $350 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $350 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total you owe is $233.46, which is less than the standard $350 copayment 
for an MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on January 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3020).  
 
You asked the Plan to pay for foot orthotics. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
(L3020).