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

 
We decided that the Plan does not have to pay more for prophylaxis - adult (D1110) provided on December 27, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like to be reimbursed for 
services you received. 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. Enrollees must pay 50% 
coinsurance for covered out-of-network dental services and may be billed by the out-of-network provider for 
any charged amount greater than the payment made by the Plan. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. The Plan has followed Medicare rules by clearly disclosing in the contract that if you choose an out-
of-network provider you pay 50% coinsurance. The allowed amount is $37 (50% x $37 = $18.50). 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 prophylaxis - adult (D1110) provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for periapical radiographic image (D0220), the resin-based 
composites (D2392 and D2393) for tooth #18, #21, and #29 and to pay for the core buildup (D2950) for tooth 
#18 provided by an out-of-network provider on December 22, 2022, and December 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were never told the dental service was 
not 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. Also, the 
denial of payment for the core buildup is correct because it is not covered by the 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. 
 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. The 
core buildup is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have 
to pay more for periapical radiographic image (D0220), the resin-based composites (D2392 and D2393) for 
tooth #18, #21, and #29 and to pay for the core buildup (D2950) for tooth #18 provided by an out-of-network 
provider on December 22, 2022, and December 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service December 
12, 2022. 
 You asked the Plan to pay for procedure code 71045. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 71045 is bundled into payment for code 
36556. 
 
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 71045 
is a column II code to column I code 36556. 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 71045 billed for date of service December 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on August 4, 
2022, by an OON provider. 
 
You asked the Plan to pay for the esophagogastroduodenoscopy. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says that this service was not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The contract also says that the POS option only applies to non-
Medicare covered dental services. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy provided on 
August 4, 2022, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - three surfaces, posterior 
(D2393) provided on January 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were given an inaccurate estimate of 
your cost share, so you believe you should not have to pay the billed amount. 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 resin-based composite - three surfaces, 
posterior (D2393) provided on January 18, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on December 26, 
2022. 
 
You asked the Plan to pay for opioid treatment services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service was billed by an individual provider and not a facility. 
Based on this information, we decided that Medicare rules for coverage of opioid treatment services have not 
been met. Therefore, we decided that the Plan does not have to pay for opioid treatment services (G2067) 
provided on December 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment services provided on 
December 12, 2022. 
 
You asked the Plan to pay for the medication assisted treatment services. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OTP services are only payable to OTP facilities. 
 
 We looked at the file and Medicare rules. Review of the file shows that these services were billed by the 
physician and not the OTP facility. This claim is not payable as billed. Based on this information, we decided 
that Medicare rules for coverage of the medication assisted treatment services have not been met. Therefore, we 
decided that the Plan does not have to pay for the medication assisted treatment services provided on December 
12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on December 26, 
2022. 
 
You asked the Plan to pay for the opioid treatment services. You say that this service was medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B coverage is available for 
outpatient Opioid Treatment Program (OTP) services provided by hospitals, Critical Access Hospitals (CAHs), 
and Free-Standing Opioid Treatment Program facilities. 
 
We looked at the file and Medicare rules. This service was billed by an individual provider and not an 
approved facility. Based on this information, we decided that Medicare rules for coverage of the opioid 
treatment services have not been met. Therefore, we decided that the Plan does not have to pay for opioid 
treatment services (G2067) provided on December 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for a dermatology specialist office visit 
provided on December 5, 2022, by an OON provider. 
 
You asked the Plan to provide reimbursement for the specialist office visit. You say that this was an 
emergency, and you made an appointment with the first available provider. The Plan denied your request. The 
Plan says that this service was not authorized and is not covered with an OON provider. 
 
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 provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. The contract also says that the POS 
benefit only applies to limited OON services in Puerto Rico. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for a dermatology 
specialist office visit provided on December 5, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on March 17, 2022. 
 
You asked the Plan to pay for wound care. You say that you say that the member was in a nursing home and 
was unable to obtain 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 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 wound care provided on 
March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
January 5, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were not purchased through the Plan's select hearing aid provider. 
 
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 purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were not purchased from 
the Plans select hearing aid provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261) purchased on January 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's admission to an Inpatient 
Rehabilitation Facility is needed. The Plan denied your request. The Plan says the enrollee's records do not 
show the need for an intensive team for your care, services needed can be provided safely in other settings, at a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) and the 
surgical access to an implant body (D6011) for tooth #31. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied implant 
services. The Plan denied your request. The Plan says your benefit for the requested items or services 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 Plan has already pre-approved 2 implant services on January 25, 2023; therefore, the enrollees 
benefit for the requested items or services was exhausted on the date of authorization of January 25, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010) and the surgical access to an implant body (D6011) for tooth #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that you need the CGM because you cannot get the 
transmitter and sensor separated. The Plan denied your request. The Plan says the Medicare criteria was not 
met. 
  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for a colonoscopy and office 
visit provided from August 17, 2022, to September 20, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for the colonoscopy and office visit. You say that 
you were not informed of the 40% coinsurance for this provider. 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 40% 
coinsurance for surgery or other services provided at an outpatient hospital (out-of-network) and a $65 
copayment for specialist services.  
 
You have been asked to pay a 40% coinsurance for the colonoscopy . This item/service falls within the surgery 
or other services provided at an outpatient hospital (out-of-network) benefit category. You have also been 
asked to pay a $20 copayment for the office visit, which is less than the $65 copayment per the EOC. 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 and copayment for a colonoscopy and office visit provided 
from August 17, 2022, to September 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 73120 billed for date of service December 8, 
2022. 
 You asked the Plan to pay for procedure code 73120. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 73120 is bundled into payment for code 
73130. 
 
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 73120 
is a column II code to column I code 73130. 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 73120 billed for date of service December 8, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided by an out-of-
network provider on December 20, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by the enrollee's 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 the enrollee 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 periodontal maintenance (D4910) provided by an out-of-network provider on December 20, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (92557) and radiology services (70486) 
provided on April 27, 2022. 
 
You asked the Plan to pay for the office visit and radiology services. You say that this service should be 
covered. 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 $65 
copayment for Out-of-Network office visits and a 50% coinsurance for out-of-network advanced imagining. 
 
You have been asked to pay the Medicare allowable amounts: a $43.28 copayment for the office visit, and a 
$75.72 coinsurance for the imaging service. 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 pay for an office visit (92557) and 
radiology services (70486) provided on April 27, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64856 and 64772 for date of service 
November 10, 2022. 
 
You asked the Plan to pay for procedure codes 64856 and 64772. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says these services are included in the global surgical package 
of a surgery procedure. 
 
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 64856 is suture of major peripheral nerve, arm or leg, 
except sciatic; including transposition. 
 
The CPT Code Manual definition of code 64772 is transection or avulsion of other spinal nerve, extradural. 
 We find that CPT codes 64856 and 64772 are not supported in the medical record. Specifically, these services 
are included in the global surgical package of procedures 22610 (Arthrodesis, posterior or posterolateral 
technique, single interspace; thoracic (with lateral transverse technique, when performed)) and 22212 
(Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic). This means these 
codes are not payable as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 64856 and 64772 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 64856 and 64772 for date of service November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of lateral exostosis, maxilla or mandible 
(D7471). 
 
You asked the Plan to pre-approve removal of lateral exostosis, maxilla or mandible. You say that this should 
be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 pre-approve 
removal of lateral exostosis, maxilla or mandible (D7471).