Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Psychiatric diagnostic evaluation provided on October 18, 
2022. 
 
You asked the Plan to pay for Psychiatric diagnostic evaluation. You say that you did not know the provider 
was not in-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 Psychiatric diagnostic 
evaluation provided on October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac monitoring services provided on September 07, 
2022. 
 
You asked the Plan to pay for cardiac monitoring services. You say that this was medically necessary and 
should be covered. 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 cardiac monitoring 
services provided on September 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing service (V5299) provided on December 9, 2022. 
 
You asked the Plan to pay for the hearing service. You say that you do not have a list of in-network providers, 
and nobody sent one. The Plan denied your request. The Plan says you exceeded the benefit maximum of 
$1,700.00 towards your hearing aids benefit. The Plan also says that you were previously reimbursed for 
hearing aids purchased on April 12, 2021, the maximum amount of $1,700 for hearing aids, and it has not been 
24 months since the last date you purchased hearing aids. 
 
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 up to $1,700 every 24 months. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing service have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing service (V5299) provided on December 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on December 09, 2022. 
 
You asked the Plan to pay for podiatry services. You say that the services should be covered. 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 podiatry services 
provided on December 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the periodic oral evaluation (D0120), dental 
cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) provided on January 30, 2023. 
 
You asked the Plan to issue reimbursement for the dental services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit when 
received from an out-of-network provider.    
Therefore, we decided that the Plan does not have to issue reimbursement for the periodic oral evaluation 
(D0120), dental cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) provided on 
January 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic services provided on 
December 05, 2022. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that you have only had a $20 
copayment in the past. 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 $55 
copayment for out-of-network chiropractic services. 
 
You have been asked to pay a $55 copayment for the chiropractic services. This item/service falls within the 
out-of-network chiropractic 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. However, since the allowed amount is less than the standard copayment, you 
only owe $38.56. Therefore, we decided that the Plan does not have to waive the copayment for the 
chiropractic services provided on December 05, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on September 19, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment The Plan denied your request. The Plan says that the services are not supported. 
 
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. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
services would not be covered. Without this information, we cannot determine whether the laboratory order 
made constituted plan-directed care. This information should be provided by the Plan. Therefore, we decided 
that the Plan has to pay for the laboratory services provided on September 19, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, mandibular partial denture, and 
removable unilateral partial denture (D0140, D5214, D5282) provided on September 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 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 March 24, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, mandibular partial 
denture, and removable unilateral partial denture (D0140, D5214, D5282) provided on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on December 15, 2022. 
 
You asked the Plan to pay for initial nursing facility care. You say that the services should be covered. 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 initial nursing facility 
care provided on December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopic pyloromyotomy. 
 
You asked the Plan to pre-approve laparoscopic pyloromyotomy. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 laparoscopic pyloromyotomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found all cited authors agree that gastric peroral endoscopic myotomy (G-POEM) 
is still a novel technique that while promising is not standard-of-care. Available records document that the 
enrollee's heartburn has responded to acid suppression treatment, and as such she cannot be classified as medically refractory. In addition, her gastroparesis has responded to intrapyloric botox injection which does not 
appear to have been re-offered. Further, the last gastric emptying scan was performed 4 years ago and at the 
time showed only mild gastric retention at 4-hours. G-POEM is not medically necessary based on provided 
records and may not at this time represent her best or safest treatment option. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laparoscopic pyloromyotomy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve laparoscopic pyloromyotomy.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on July 6, 2022, billed with codes 
74230, 72040, 70100, and 99204. 
 
You asked the Plan to pay for the imaging services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the imaging services provided have not been met. The procedure is a barium swallow study, and 
this means that it involves the administration of a substance to the enrollee.  Therefore, we decided that the 
Plan does not have to pay for imaging services provided on July 6, 2022, billed with codes 74230, 72040, 
70100, and 99204.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 1, 2023, to January 4, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told you 
would not be billed for the stay. 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 $240 
copayment per day, for days 1 to 5 for each admission to an in-network Medicare-covered inpatient hospital 
stay.  
 You have been asked to pay a $240 copayment per day, for days 1 to 3 of the inpatient hospital stay. You have 
been asked to pay a total of $720 ($240 copayment x 3 days = $720). You have not been charged for any 
additional days. 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 the inpatient hospital stay provided from January 1, 2023, to January 
4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental implant (code D6057) and a porcelain/ceramic 
crown anchored to an implant abutment (code D6058) provided on October 12, 2022. 
 
You asked the Plan to pay for the dental implant (code D6057) and the porcelain/ceramic crown anchored to an 
implant abutment (code D6058). You say that the services were medically necessary. The Plan denied your 
request. The Plan says these dental services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a dental 
implant  (code D6057) and a porcelain/ceramic crown anchored to an implant abutment (code D6058) provided 
on October 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary, your tooth must have noticeable bone 
loss or show on an x-ray that there is a hard substance built up on the root of the tooth. Your x-rays do not 
show that you have these issues. 
 
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 Plan covers deep gum and 
root cleaning when the services are medically necessary and reasonable.  
 
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 deep gum and root cleaning. Our reviewer says that the service is not medically necessary. Our physician reviewer found there was no record of 
periodontal pocket charting, and the radiographs did not indicate areas of bone loss or areas of calculus 
accumulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of deep gum and root cleaning have not been met. Therefore, we decided that the 
Plan does not have to pre-approve deep gum and root cleaning (D4341) for all 4 quadrants.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 38724 and 31600 billed for date of service 
August 3, 2021. 
 
You asked the Plan to pay for procedure code 38724 and 31600. You say that this should be paid for. The Plan 
denied your request. The Plan says payment for code 38724 is bundled into payment for code 41145, and 
31600 is bundled into payment for 41145. 
 
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 38724 is a column II code to column I code 41145. 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.   
 
Additionally, code 31600 is a column II code to column I code 41145. This edit has a modifier indicator of 0. 
The column II code is therefore not payable. 
 
Therefore, we decided that the Plan does not have to pay for procedure code 38724 and 31600 billed for date of 
service August 3, 2021.
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 
January 3, 2023.  
 
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 January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Stonehenge Health Dynamic Brain Supplement 
purchased on February 27, 2023. 
 
You asked the Plan to pay for the Stonehenge Health Dynamic Brain Supplement. You say that you were 
previously taking Neuriva Plus, which was covered under your benefits. You also say that when comparing 
both brands, the Dynamic Brain brand has a much more robust list of vitamins versus the Neuriva Plus brand, 
and you believe it should be an eligible expense under your benefits. The Plan denied your request. The Plan 
says this is not covered under your contract under any normal circumstances. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. Though your 
Plan offers supplemental coverage for specific OTC item, the Stonehenge Health Dynamic Brain Supplement is 
not included on the list of eligible items. Therefore, we decided that the Plan does not have to pay for the 
Stonehenge Health Dynamic Brain Supplement purchased on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) and eye 
refraction (92015) provided on October 7, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit and eye refraction. You say that you 
should be entitled to coverage, and you do not feel you should have to pay the $40.00 out of pocket. 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 
copayment for each Medicare-covered eye exam under the Vision care benefit category.  
 
 You have been asked to pay a $40 copayment for the outpatient office visit and eye refraction. This 
item/service falls within the Vision care benefit category. This was not a routine exam but was a medical exam 
for the diagnoses of, H00.12 (Chalazion right lower eyelid) and H16.143 (Punctate Keratitis bilateral) 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 the outpatient office visit (99212) and eye refraction 
(92015) provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 25, 2023. 
 
You asked the Plan to pay for wound care services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 services 
provided on January 25, 2023.