Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by an 
in-network provider from January 18, 2022, to January 24, 2022.  
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel that the 
enrollee is not liable. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment per day, for days 1-5, for in-network Medicare-covered inpatient hospital stays. 
 
 The enrollee has been asked to pay a $1500 copayment for the inpatient hospital stay ($300 copayment x 5 
days = $1500). This item/service falls within the inpatient hospital care benefit category. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the inpatient hospital stay provided by an in-network provider from 
January 18, 2022, to January 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram and office visit provided on April 19, 
2023. 
 
You asked the Plan to pay for the electrocardiogram and office visit. You say that you are requesting 
reconsideration of the denied claim. 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 electrocardiogram 
and office visit provided on April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 24, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit, and related services provided on 
October 26, 2022. 
 
You asked the Plan to pay for a new patient office visit, and related services. You say that these 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 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 new patient office 
visit, and related services provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for radiation therapy on May 02, 2023.  
 
You asked the Plan to waive the deductible for radiation therapy. You say that you want to appeal the amount 
being charged. 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. Your 
contract with the Plan says that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $525 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time 
radiation therapy was received on May 2, 2023. Therefore, we decided that the Plan does not have to waive the 
deductible for radiation therapy on May 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and radiologic examination provided on April 
25, 2023. 
 
You asked the Plan to pay for an office visit and radiologic examination. You say that this service is supported 
in the records. 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 and 
radiologic examination provided on April 25, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 24, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient was treated in good faith in a facility. 
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 facility visit provided 
on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principal care management services provided on May 24, 
2023. 
 
You asked the Plan to pay for the principal care management services. You say that you are requesting 
reconsideration of the denied claim. 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 principal care 
management services provided on May 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81194 and 81301 billed for date of service 
December 16, 2022. 
 
You asked the Plan to pay for procedure codes 81194 and 81301. You say that medical documentation was 
submitted. The Plan denied your request. The Plan says payment for codes 81194 and 81301 are bundled into 
payment for code 81455. 
 
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 codes 81194 and 81301 are column II codes to column I code 81455. The 
records do not show that codes 81194 and 81301, billed with the XU modifier, were distinct unusual non-
overlapping services. 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 codes 81194 and 81301 billed for date of service 
December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and electrical stimulation provided by a 
chiropractor on May 19, 2023. 
 
You asked the Plan to pay for an office visit and electrical stimulation. The Plan denied your request. The Plan 
says The Plan says that an office visit and electrical stimulation is not a covered benefit when billed by a 
chiropractor. 
 
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 an office visit and electrical stimulation provided by a chiropractor on May 
19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 20, 
2023. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 83789 is bundled into 
payment for codes 80307 and G0480. 
 
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 83789 
is a column II code to column I codes 80307 and G0480. The records do not support the billed 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 83789 billed for date of service March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 95816-26 billed for date of service April 19, 2022. 
 
You asked the Plan to pay for code 95816-26. You say that medical records have been supplied to support 
payment. The Plan denied your request. The Plan says code 95816-26 is not supported by the medical record. 
The records do not include documentation of this service. 
 
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 95816-26 is electroencephalogram (EEG); including 
recording awake and drowsy.  

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 95816-26. Our reviewer says that code 95816-26 is not 
supported by the medical record. Our reviewer found the medical record did not include a procedure report for 
EEG recording awake and drowsy, and therefore cannot be verified. For CPT 95816, electroencephalogram or 
EEG is a diagnostic test that uses small electrodes attached to the scalp to measure the electrical activity of the 
brain. In this procedure the provider performs the EEG during awake and drowsy states of the patient.  This 
procedure was not documented, and therefore cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 95816-26 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 95816-26 billed for date of service April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for in-network dialysis treatments provided on 
January 02, 2023, to January 06, 2023. 
 
You asked the Plan to waive the coinsurance for in-network dialysis treatments. You say that you thought you 
had reached your out-of-pocket maximum and are not sure why you owe so much. 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 20% 
coinsurance for services to treat kidney disease. 
 
You have been asked to pay 20% coinsurance for in-network dialysis treatments. This item/service falls within 
the services to treat kidney disease 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 coinsurance for 
in-network dialysis treatments provided on January 02, 2023, to January 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 for date of service December 12, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code 95941 is not payable by 
Medicare. 
 
We looked at the file and Medicare rules. The services at issue are billed with code 95941. This code is 
specifically not covered. Based on this information, we decided that Medicare rules for coverage of procedure 
code 95941 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
95941 for date of service December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 22, 2023. 
 
You asked the Plan to pay for an office visit. You say that you say that you were not aware that the specialist 
was not in the plans network. 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 February 22, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 22, 2023. 
 
You asked the Plan to pay for lab services. You say that these 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 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 lab services provided on 
May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), panoramic radiographic image (D0330), and 
prophylaxis - adult (D1110), provided on May 23, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you checked with your dental office and 
they confirmed they did bill the plan. You also say that you assumed this meant you would be fully covered for 
the total 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 a periodic oral evaluation - established 
patient (D0120), bitewings - four radiographic images (D0274), panoramic radiographic image (D0330), and 
prophylaxis - adult (D1110), provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) for tooth #31 provided on March 28, 
2023. 
 
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 denial of payment for this service is correct, because the extraction 
is not covered by the Plan or Medicare. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) for tooth 
#31 provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-autogenous connective tissue graft (D4275) for tooth 
#24 and #36 and the gingivectomy (41820) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the treatment plan was recommended by your 
dentist and the oral surgery falls under your medical. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the non-autogenous connective tissue graft is not covered by the 
Plan and there was no approved authorization for the gingivectomy. 
 
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 requested non-autogenous connective tissue graft and gingivectomy in dispute meets the Medicare 
definition of dental, since it is a service which involved the care and treatment of teeth or structures directly 
supporting the teeth. The non-autogenous connective tissue graft and gingivectomy does not fall under any of 
Medicare exceptions for coverage of non-routine dental care. 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 non-autogenous connective tissue graft 
(D4275) for tooth #24 and #36 and the gingivectomy (41820) provided on May 2, 2023.