Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for radiological services provided on October 7, 2022, billed with code 
76870. 
 
You asked the Plan to pay for the radiological services provided You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says that the modifier required for this procedure code 
is missing. 
 
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. We find that the specific denial rational offered by the plan is not supported. The 
plan states that the patient status listed on the claim indicates that the patient was in custody when the services 
were provided and are not payable unless billed with a valid modifier. The plan has not provided actual 
evidence that the enrollee was listed in custody on the date the services were provided. Therefore, we decided 
that the Plan has to pay for radiological services provided on October 7, 2022, billed with code 76870.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total knee replacement to be rendered by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the total knee replacement. You say that the enrollee has been coming to 
your office for over 10 years. The Plan denied your request. The Plan says the provider is not in the Plan's 
network. The Plan also says there are in-network providers that can provide the requested services. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 the total knee replacement. Our 
reviewer says that a total knee replacement to be rendered by an OON provider is not medically reasonable and 
necessary. Our physician reviewer found detailed documentation is not evident regarding any significant 
abnormalities that would require OON (additionally specialized) treatment for the left knee. The enrollee has 
had two pre-operative history and physicals and was cleared to proceed with the surgery. Our reviewer found 
there were no other examinations provided that support this enrollee has been treating or is undergoing current 
treatment with a specific, specialized provider and would not be able to continue care with a different 
orthopedic provider. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Our physician reviewer found that therefore, this enrollees 
medical management and/or follow-up care could be safely transitioned to an in-network orthopedic specialist 
at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the total knee replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a total knee replacement to be rendered by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear purchased on November 9, 2022. 
 
You asked the Plan to pay more for the eyewear. You say that the Explanation of Benefits (EOB) states $300 
coverage for eyeglasses. The Plan denied your request. The Plan says the maximum benefit allowance of $150 
has already been issued to you. The Plan also says that no further payment by the Health Plan is due. 
 
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 reimburses up to $150 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The record shows that the Plan issued payment in the amount of $150 
to you on January 14, 2022, and your prescription eyewear allowance has been exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay more for the eyewear purchased on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says you 
do not have a qualifying wound for coverage of compression stockings.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on 
October 3, 2022, to October 6, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with this 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $295 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $885 ($295 x 3 days = $885). This item/service falls within the inpatient hospital 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 copayment for an inpatient hospital stay 
provided on October 3, 2022, to October 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74018 billed for date of service October 11, 
2022. 
 
You asked the Plan to pay for procedure code 74018. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 74018 is 3. The MAI value for this code is 3. You billed 4 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 74018 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 74018 billed for date of service October 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) rendered by 
an out-of-network (OON) provider from August 25, 2022, through December 1, 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 were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal.  The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay 
for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative 
treatments (98941) rendered by an out-of-network (OON) provider from August 25, 2022, through  
December 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each cataract surgery provided on May 25, 
2022, to June 15, 2022. 
 
You asked the Plan to waive the copayment for each cataract surgery. You say that you were not made aware 
of this copayment and you cannot afford it. 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 surgery. 
 
You have been asked to pay a $350 copayment for each cataract surgery. 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. Therefore, we decided that the Plan does not have to waive the copayment for each cataract surgery 
provided on May 25, 2022, to June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 21, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services 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 you met your $1,500 yearly allowance during this visit. 
 
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 January 10, 2023. 
Therefore, we decided that the Plan does not have to pay for dental services provided on January 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 04, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting a reconsideration for this claim. 
The patient saw a physicians assistant PA, not a nurse practitioner (NP). 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 an office visit provided 
on October 04, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on November 22, 2022, to 
December 21, 2022. 
 
You asked the Plan to pay for the home health services. You say that authorization for these services is not 
required per Availity. 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 the home health services 
provided on November 22, 2022, to December 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room visit provided on 
December 04, 2022, to December 05, 2022. 
 
You asked the Plan to waive the copayment for each emergency room visit. You say that you should have been 
admitted as an inpatient. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for each emergency room visit. This item/service 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 copayment for each emergency 
room visit provided on December 04, 2022, to December 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #4 and #5 provided on 
January 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told the difference would only be $10 
and no one told you it would be more or else you would have gone somewhere else. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because core buildup 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. 
 
  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 core 
buildup (D2950) for tooth #4 and #5 provided on January 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollees doctor is responsible for 
obtaining authorization for these services. 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 the laboratory services 
provided on January 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee x-ray provided on January 06, 2023. 
 
You asked the Plan to pay for a knee x-ray. You say that please reconsider this claim for approval, as it was 
necessary to treat the patient. 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 a knee x-ray provided on 
January 06, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on December 07, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
went to the ER, then were admitted as inpatient, and should not have this $50 copayment. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copayment for outpatient hospital services. 
 
You have been asked to pay a $50 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. You were not admitted to the hospital as an inpatient, you were put into 
outpatient observation. This is different from being admitted. Therefore, we decided that the Plan does not have 
to waive the copayment for an in-network emergency room (ER) visit provided on December 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120), provided on January 16, 2023. 
 
You asked the Plan to pay for a complete maxillary and mandibular denture. You say that you were told these 
would be covered and now you're being told they are not. The Plan denied your request. The Plan says D5110 
and D5120 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 a 
complete maxillary and mandibular denture (D5110/D5120), provided on January 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on November 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 April 9, 2021. Therefore, 
we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for amalgam - two surfaces, primary or permanent 
(D2150) provided on February 15, 2023. 
 
You asked the Plan to pay more for dental services. You say that due to issues that you have had with the 
provider, you do not think you should have to pay for the services received. The Plan denied your request. The 
Plan says we will be unable to waive the copayment for these services. 
 
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 amalgam 
- two surfaces, primary or permanent (D2150). The Plan covers this with a 50% coinsurance up to maximum 
dental allowance. 
 
The allowed amount of the covered services is $88, resulting in a coinsurance amount of $44 and a Plan 
payment of $44. 
 
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 amalgam - two surfaces, primary or permanent (D2150) 
provided on February 15, 2023.