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

 
We decided that the Plan does not have to pay for the self-administered drugs received on November 30, 2022, 
through December 1, 2022.  
 
You asked the Plan to pay for the self-administered drugs. You say that you are receiving a bill from the 
provider and are not able to afford the payment. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 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. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on November 30, 2022, through December 1, 2022.   
 
Benefits for the 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on November 18, 2021, 
through November 19, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that the services should be reviewed as you 
already paid your co-pay. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 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. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on November 18, 2021, through November 19, 2021.  
 
Benefits for the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental restoration services (D2975) provided on June 1, 2022
 . 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
restoration services (D2975) provided on June 1, 2022 .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of an impacted tooth and dental office visit 
(D7240, 99203) provided on November 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction of an impacted tooth and dental office visit (D7240, 99203) provided on November 1, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service November 
17, 2022.  
 You asked the Plan to pay for procedure code A0425. You say that you would like the Plan to reconsider their 
denial of payment. 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 claims submitted where the unit of service 
exceeds the MUE value can be paid with an appropriate modifier, on separate lines, when the MAI value is 1. 
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 273 units of 
this code on one line, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of procedure code A0425 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A0425 billed for date of service November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140), and immediate denture - mandibular  (D5140) provided on November 21, 2022, to 
January 2, 2023. 
 
You asked the Plan to pay for the extractions, and immediate denture - mandibular. You say that you were told 
extractions and dentures were covered and now you received a bill that says the services are not covered.  The 
Plan denied your request. The Plan says these services are not covered under the benefit package.  
 
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 extractions, erupted tooth or 
exposed root and immediate denture  mandibular are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for extractions, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140), and immediate denture - mandibular  (D5140) provided on November 21, 2022, to 
January 2, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF visit provided from February 3, 
2023, to February 24, 2023 
 
You asked the Plan to waive the copayment for a SNF visit. You say that you do not understand why you are 
being billed a 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 $0 
copayment for days 1 to 20 and a $196 copayment each day for days 21 to 100 for SNF care.  
 
 
  You have been asked to pay $196 for a SNF visit. This item/service falls within the SNF 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 a SNF visit provided from February 3, 2023, to February 24, 
2023
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
April 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service 
because it is a covered benefit. 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 the date of service of April 3, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on April 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on March 21, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you would 
like a refund for the copayment because the CT scan should have been covered as part of the colon cancer 
diagnosis. 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 $160 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $160 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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 a 
computed tomography (CT) scan provided on March 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax. 
 
You asked the Plan to pre-approve the CT scan. You say that the test was ordered due to the enrollee's 
symptoms of weight loss, rectal bleeding, and early satiety. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found review of the record shows the enrollee has 
greater than a 20 pack-year history of smoking and quit in 2014. The requested CT scan is not the 
recommended test, as a low dose computed tomography (LDCT) is more appropriate for the enrollee's 
condition. 
 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on December 24, 2021, to 
January 7, 2022. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the claim 
was untimely, and the submission did not meet the exception criteria guidelines. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until February 9, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services provided on December 24, 2021, to January 
7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 14-day continuous glucose monitor 
(CGM) sensor to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee disagree 
with the denial. The Plan denied your request. The Plan says the items denied correctly as they were non-
emergent. The supplies can be provided in-network. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. 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 
a freestyle libre 14-day continuous glucose monitor (CGM) sensor 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 the comprehensive oral evaluation (D0150) provided on 
March 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that you went to a new provider to get a second 
opinion and the dentist needed to examine your teeth. 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 the Plan paid for a comprehensive oral evaluation (D0150) on January 25, 2023; therefore, your benefit 
for the requested item or service was exhausted on the date of service of January 25, 2023. Therefore, we 
decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on March 
21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs received on October 10, 2021, 
through October 14, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you disagree with the denial and ask 
for reconsideration of payment. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 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. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
received on October 10, 2021, through October 14, 2021.  
 
Benefits for the 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on March 8, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that you 
contacted the Plan prior to the date of service and did your due diligence to ensure you would not owe for 
services. The Plan denied your request. The Plan says your benefit for the intraoral - complete series of 
radiographic images 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 intraoral - complete series of radiographic images was exhausted on date of service 
February 26, 2021. Therefore, we decided that the Plan does not have to pay for intraoral - complete series of 
radiographic images (D0210) provided on March 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on February 3, 2023. 
 
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 this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99213) provided on February 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99213-25 billed for date of service March 8, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the service should be paid. The Plan denied your 
request. The Plan says an appropriate modifier was not 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. 
 
We find that CPT code 99213-25 was billed on the same day as minor procedure code 11102. The medical 
records provided do not show the evaluation and management service was a significantly separate identifiable 
service. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 99213-25 billed for date 
of service March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infectious agent detection by nucleic acid (DNA or 
RNA), multiple organisms; amplified probe(s) technique (87801) provided on August 5, 2022. 
 
You asked the Plan to pre-approve the service. You say that you are requesting reconsideration of the claim. 
The Plan denied your request. The Plan says the claim billed with diagnosis N390 which per CMS.gov is not 
on the list of required diagnosis for this test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pre-approve the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for diagnosis of a urinary tract infection (UTI) is a urine culture with 
sensitivities. The review has determined that the items/services at issue in this case were not medically reasonable and necessary. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified 
probe(s) technique (87801) provided on August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental services on January 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you require additional transportation 
trips to attend future appointments for knee injections and physical therapy. The Plan denied your request. The 
Plan says you have exceeded the limits set in the subscriber agreement. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way non-emergency transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on May 9, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary.  The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rehabilitation therapy services provided from July 6, 
2022, to July 30, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was resubmitted with the correct bill 
type. The Plan denied your request. The Plan says the rules for payment have not been met. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim at issue was not submitted with a bill type suitable for payment. 
Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for the rehabilitation therapy services provided 
from July 6, 2022, to July 30, 2022.