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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 20, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not think you 
should owe anything for this service. 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 in-network emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
in-network emergency room 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 emergency room visit provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 19, 2022. 
 
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 services are not covered 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 the dental 
services on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) and periapical first film 
(D0220) provided on January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 June 6, 2022, and 
October 17, 2022. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) 
and periapical first film (D0220) provided on January 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93976 billed for date of service November 
20, 2022. 
 You asked the Plan to pay for procedure code 93976. You say that the procedure code 93976 is not bundled 
into another procedure code. The Plan denied your request. The Plan says payment for code 93976 is bundled 
into payment for code 93975. 
 
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 93976 
is a column II code to column I code 93975. 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 93976 billed for date of service November 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the annual wellness visit, and the office 
visit provided on November 15, 2022. 
 
You asked the Plan to reduce the cost share for the annual wellness visit and the office visit. You say that you 
would like the Plan to reconsider this claim. 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 50% 
coinsurance for out-of-network annual wellness visits. Your contract with the Plan also clearly says that you 
must pay a $65 copayment for out-of-network provider and professional services. 
 
You have been asked to pay $65.20, which is 50% coinsurance of the allowed amount for the annual wellness 
visit ($130.40 allowed amount x 50% = $65.20). This item/service falls within the annual wellness visit benefit 
category. You have also been asked to pay a $65 copayment for the office visit. This item/service falls within 
the physician/practitioner services, including doctor's office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to reduce the cost share for the annual wellness visit, and the office visit provided on November 15, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the extraspinal chiropractic manipulative treatment (98943) provided 
on September 30, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the service provided in this case is not a 
covered benefit. However, the Plans contract provides supplemental coverage for unlimited visits each 
calendar year with a licensed chiropractor for additional services beyond the Medicare-covered benefit. The 
Plans contract does not state the additional chiropractic services that are covered under the supplemental 
benefit, nor does it state that the service at issue in this case is not covered. 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 extraspinal 
chiropractic manipulative treatment (98943) provided on September 30, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0140, D2980) on December 16, 2022. 
 
You asked the Plan to pay for the dental services (D0140, D2980). You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the requested 
service (D0140) has already been exhausted. The dental service (D2980) 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 22, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0140, D2980) on December 
16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on August 17, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory testing 
provided on August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on November 10, 2022. 
 
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 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 27, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service April 22, 
2022. 
 You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220. 
 
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 99497 
is a column II code to column I code 99220. 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 99497 billed for date of service April 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 32650 provided on August 19, 2022. 
 
You asked the Plan to pay for procedure code 32650. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this claim cannot be paid as 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. 
 
In this case, the CPT Code Manual definition of code 32650 is Thoracoscopy, surgical; with pleurodesis (eg, 
mechanical or chemical). 
 
We find that CPT code 32650 is not supported in the medical record. Specifically, a required anatomical 
modifier was not billed for this code. Based on this information, we decided that Medicare rules for coverage 
of procedure code 32650 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 32650 provided on August 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the requested Botox is medically necessary. The Plan 
denied your request. The Plan says the enrollee must have documentation of an inadequate response to or 
intolerance of at least one oral agent which may include one of the following: carbamazepine, baclofen, or a 
benzodiazepine, or the provider has determined that these oral treatments are clinically inappropriate. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical records 
provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services (99285) provided on 
November 8, 2022. 
 
You asked the Plan to pay for the emergency department services. You say that the medical records support the 
billing of code 99285. The Plan denied your request. The Plan says the medical records do not support the 
billing of code 99285. 
 
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, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the emergency department services. Our reviewer says that 
the medical records do not support the billing of code 99285. Our reviewer found the review has determined 
that the billed code 99285 was not substantiated by the clinical documentation. The member was 
hemodynamically stable, with normal vital signs and unremarkable lab work. There was no sign of multisystem 
dysfunction, a condition that posed an immediate life threat, nor no acute situation of a complex nature to 
support the level of care billed. No specialty consults or extensive decision making was required. No critical or 
extensive care was involved. The review has determined that the medical records supported a comprehensive 
history and a comprehensive examination but did not support medical decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided 
that the Plan does not have to pay for the emergency department services (99285) provided on November 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for maxillary partial denture - cast metal framework with resin 
denture bases (including retentive/clasping materials, rests and teeth) (D5213) and extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated 
(D7210) provided on August 25, 2022, and December 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you would like the Plan to pay for services, because 
you could not chew and were missing teeth. The Plan denied your request. The Plan says these services are not 
covered under your 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. Maxillary partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5213 and D7210 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5213) and extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided on August 25, 2022, and 
December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) provided on January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that your coverage had 
changed and you were allowed to use only PPO providers. 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 a crown - porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) 
provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on December 8, 2022, by an 
out-of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that these services should be covered. 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 dental services provided on December 8, 
2022, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 19, 2022 to 
September 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 19, 2022 to 
September 9, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the hearing aid repair service (V5299) provided on 
January 9, 2023. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says that the service at issue is not 
payable as it was rendered by an out-of-network provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has stated that the service at issue in this case is not 
payable as it was rendered by an out-of-network provider. However, the Plan has not provided the Evidence of 
Coverage (EOC) contract for the year 2023, in which this service was rendered. We are unable to determine the 
allowable coverage for this service provided. The Plan has not substantiated their denial; therefore, we must 
find in your favor. Therefore, we decided that the Plan has to issue reimbursement for the hearing aid repair 
service (V5299) provided on January 9, 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.