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

 
We decided that the Plan does not have to waive the cost for an ER visit, and self-administered drugs provided 
from August 25, 2023, to August 26, 2023. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you disagree 
with the amount charged. The Plan denied your request. The Plan says this cost 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 $95 
copayment for emergency care.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay $127 for an ER visit and self-administered drugs. This total includes a $95 
copayment for an ER visit and $32 for self-administered drugs. The $95 copayment was charged because the 
ER copayment still applies when admitted to outpatient observation. The ER visit falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost for an ER visit, and self-administered drugs 
provided from August 25, 2023, to August 26, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 26, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says there was no authorization on file for these services. 
  
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 office visit provided on May 26, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are 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.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of desensitizing medicament (D9910), 
periodontal scaling and root planing (D4341), and localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue (D4381), periodontic evaluation (D0180), and comprehensive x-
rays (D0210) provided from August 28, 2023, to September 21, 2023. 
 
  You asked the Plan to pay for application of desensitizing medicament, periodontal scaling and root planing, 
and localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, 
periodontic evaluation, and comprehensive x-rays. You say that you called the Plan on October 2, 2023, and 
were told these services were going to be covered.  The Plan denied your request. The Plan says these services 
are not covered under this 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 
application of desensitizing medicament (D9910), periodontal scaling and root planing (D4341), and localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381), 
periodontic evaluation (D0180), and comprehensive x-rays (D0210) provided from August 28, 2023, to 
September 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on August 17, 2023. 
 
You asked the Plan to pay for the dental 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 enrollees benefit for the services 
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 the enrollees benefit for the services provided was exhausted on date of service February 16, 2023.  
  
 
Specifically, the Plans contract states that one dental cleaning and one periodic oral exam are covered per year. 
The enrollee previously received these services on February 16, 2023, less than one year prior, which were paid 
for by the Plan. Therefore, the enrollee has exhausted the allowable benefit for these services. Therefore, we 
decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bitewings - four radiographic images (code D0274) provided 
on October 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that it should have been the responsibility of the 
dentist office to make you aware of this coverage. 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 service was exhausted on date of service April 10, 2023. Therefore, we decided that the Plan does not have to pay for Bitewings - four radiographic images (code D0274) provided on 
October 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adult prophylaxis (D1110) provided on October 13, 2023. 
 
You asked the Plan to pay for adult prophylaxis. You say that your contract says that there is no frequency 
limitation shown. You also say there is only a $1,500 benefit limit. The Plan denied your request. The Plan says 
this 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 adult 
prophylaxis (D1110) provided on October 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87491, 87496, 87529, 87563, 87591, 87798, 
87500, 87481, 87641, 87640, 87653, and 87651 provided on August 29, 2023. 
 
You asked the Plan to pay for procedure codes 87491, 87496, 87529, 87563, 87591, 87798, 87500, 87481, 
87641, 87640, 87653, and 87651. You say that you would like the Plan to reconsider their denial of payment. 
The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 procedure codes 87491, 87496, 87529, 87563, 87591, 87798, 87500, 87481, 
87641, 87640, 87653, and 87651 provided on August 29, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided October 20, 2022, to 
November 18, 2022. 
 You asked the Plan to pay for the home health services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 24, 2023. The NOA was not received by the Plan until April 27, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
October 20, 2022, to November 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain or ceramic retainer crown (D6740) provided on 
July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider never discussed a preauthorization 
with you. 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 July 24, 2023. Therefore, 
we decided that the Plan does not have to pay for a porcelain or ceramic retainer crown (D6740) provided on 
July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve chiropractic care to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The Plan has network providers available who are 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.) We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from July 24, 
2023, to August 22, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the services denied correctly as the enrollee does not meet 
the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from July 24, 2023, to August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residence visit provided on September 22, 2023, to 
October 6, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the residence visit. You say that you should not be penalized for providing 
medical services to the enrollee that were medically necessary. The Plan denied your request. The Plan says the 
services did 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 residence visit provided on September 22, 2023, to October 6, 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 limited oral evaluation-problem focused (D0140) 
provided on October 12, 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 25, 2023.  
  
 
Specifically, the Plans contract states that two limited oral evaluations are covered per year. You previously 
received this service on August 23, 2023 and September 25, 2023 accordingly, less than one year prior, which 
were 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 limited oral evaluation-problem focused (D0140) provided on 
October 12, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Duplex scan of extremity veins provided on August 07, 
2023. 
 
You asked the Plan to pay for Duplex scan of extremity veins. You say that the services were 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 Duplex scan of extremity veins provided on August 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), and tissue conditioning 
(D5851) provided on August 23, 2023.  
 
You asked the Plan to pay for limited oral evaluation and tissue conditioning. You say that you are not satisfied 
with your dentures. 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. 
 
 
  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 limited 
oral evaluation (D0140), and tissue conditioning (D5851) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), miscellaneous vision services 
(V2799), and lenses (V2783) provided on October 3, 2023.  
You asked the Plan to pay for progressive lenses, miscellaneous vision services, and lenses. You say that you 
were told by the Plan that you were covered for $70 once a year. You also say the claim was processed, so you 
want to know why you are not getting a check for the $70 coverage. The Plan denied your request. The Plan 
says you have already utilized the full benefit amount. 
 
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 will reimburse you up to $70 once every 24 months towards the cost of eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan will reimburse you up to $70 once 
every 24 months towards the cost of eyewear. The record shows this benefit was exhausted on September 28, 
2022. Based on this information, we decided that the Plan's rules for coverage of progressive lenses, 
miscellaneous vision services, and lenses  have not been met. Therefore, we decided that the Plan does not have 
to pay for progressive lenses (V2781), miscellaneous vision services (V2799), and lenses (V2783) provided on 
October 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections provided on July 27, 2023. 
 
You asked the Plan to waive the copayment for injections. You say that there was no surgery performed on the 
date indicated in the 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 a $200 
copayment for outpatient surgery. 
 
You have been asked to pay a $200 copayment for injections. This item/service falls within the outpatient 
surgery 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 $200 copayment for an outpatient surgery. Therefore, we decided that the 
Plan does not have to waive the copayment for injections provided on July 27, 2023.