Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for out-of-network Medicare Part B prescription 
drugs and an out-of-network office visit provided on April 19, 2023. 
 
You asked the Plan to waive the cost share for out-of-network Medicare Part B prescription drugs and an out-
of-network office visit. You say that you disagree with the cost share. 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 30% 
coinsurance for out-of-network Medicare Part B prescription drugs and a $20 copayment for out-of-network 
physician/practitioner services.  You have been asked to pay a 30% coinsurance for out-of-network Medicare Part B prescription drugs and a 
$20 copayment for an out-of-network office visit. The total allowed amount for the prescription drugs is $4.74. 
You are being asked to pay $1.42 ($4.74 x 30% = $1.42). The total amount for all services rendered is $21.42 
($20 + $1.42 = $21.42). This item/service falls within the out-of-network Medicare Part B prescription drugs 
out-of-network physician/practitioner 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. Therefore, we decided that the Plan does not have to waive the 
cost share for out-of-network Medicare Part B prescription drugs and an out-of-network office visit provided 
on April 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for date of service March 1, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the specimens are received from providers and 
must be processed without delay. The Plan denied your request. The Plan says the billed code cannot be 
verified. 
 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 88305 is surgical pathology, gross and microscopic 
examination. We find that CPT code 88305 is not supported in the medical record. The records provided 
include a gross description of the tissue exam. The records do not include a microscopic exam. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88305 billed for date of service March 1, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance code A0427-SH billed for date of service 
February 12, 2023. 
 
You asked the Plan to pay for the billed services. You say that you require compensation for the services. The 
Plan denied your request. The Plan says the documentation does not support the service provided twice on the 
same day. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied.  
 
 Code A0427 was billed with an SH modifier, indicating transport from the scene of an event to the hospital. 
We looked at the file and Medicare rules. The file shows that the services at issue were reimbursed by the Plan 
on April 10, 2023. A comparison of the two claim lines shows these are exact duplicates. There is no evidence 
presented to support that the billed service, with the SH modifier was provided twice on the same date. Based 
on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for ambulance code A0427-SH billed for date of service February 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure (D5899) 
provided on March 30, 2023. 
 
You asked the Plan to pay for the dental service. You say that you received a bill, and the Plan should pay the 
bill. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the 
unspecified removable prosthodontic procedure 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified removable prosthodontic procedure (D5899) provided on March 30, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room (ER) visit provided 
on May 25, 2023. 
 
You asked the Plan to waive the copayment for each emergency room (ER) visit. You say that the ER visit was 
urgent due to the symptoms you experienced. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for each emergency room (ER) 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 (ER) visit provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950), a pontic (D6245), and a 
retainer crown (D6740) for tooth #12, #13, and #14. 
 
You asked the Plan to pre-approve the dental services. You say that you had a tooth extracted and the dentist 
already had a treatment plan and you have been given no explanation why the services were denied. The Plan 
denied your request. The Plan says the denial of authorization for these services is correct, because the core 
buildup, pontic, and the retainer crown are 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 pre-approve the 
core buildup (D2950), a pontic (D6245), and a retainer crown (D6740) for tooth #12, #13, and #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network continuous positive airway 
pressure (CPAP) machine provided from March 7, 2023, to April 24, 2023. 
 
You asked the Plan to waive the coinsurance for a CPAP machine. You say that you have been told multiple 
times that these items should be covered at 100%. You do not understand why you keep getting bills. 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 20% 
coinsurance for durable medical equipment (DME) and related services.  
 
The total allowed amount of this item for this date of service is $302.16, resulting in a coinsurance amount of 
$60.43 ($302.16 x 20% = $60.43). You have been asked to pay a $60.43 coinsurance for a CPAP machine. This item/service falls within the 
durable medical equipment (DME) and related 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. Therefore, we decided that the Plan does not have to waive 
the coinsurance for an in-network continuous positive airway pressure (CPAP) machine provided from March 
7, 2023, to April 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for PT and OT services provided from 
January 3, 2023, to January 31, 2023. 
 
You asked the Plan to reduce the coinsurance for PT and OT services. You say that you feel the Plan should at 
least cover 80% of the cost share for the services rendered. 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 50% 
coinsurance for outpatient rehabilitation services performed by an out-of-network (OON) provider.  
 
 You have been asked to pay a coinsurance of $7,379, which is 50% of the allowed amount for PT and OT 
services ($14,758 allowed x 50% = $7,379). This item/service falls within the outpatient rehabilitation services 
performed by an out-of-network (OON) provider 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 reduce the 
coinsurance for PT and OT services provided from January 3, 2023, to January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, cone beam computed tomography 
(CT) scan, and pulp vitality tests (D0140, D0380, D0460) provided on April 5, 2023. 
 
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 April 4, 2023 (D0140). 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation, cone beam computed 
tomography (CT) scan, and pulp vitality tests (D0140, D0380, D0460) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the joint reconstruction (D7858) on 2 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that it is necessary that you get the dental 
services approved. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the joint reconstruction 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 pre-approve the 
joint reconstruction (D7858) on 2 quadrants.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 83520 and 87798 billed for date of service 
December 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that you are obligated to process the specimens 
received. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
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 83520 is immunoassay for analyte other than infectious 
agent antibody or infectious agent antigen; quantitative, not otherwise specified. The definition of code 87798 
is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism. We find that CPT codes 83520 and 87798 are not supported in the medical record. The records provided do not 
specify what immunoassay and infection agent antigen is associated with the billed codes. 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 codes 83520 and 87798 billed for date of service 
December 19, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 19, 2022, to 
May 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted multiple 
times. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from April 19, 2022, to May 
18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a contrast injection for radiological evaluation (36598), a 
heparin injection (J1642), and an alteplase recombinant injection (J2977) provided on December 19, 2022, by 
an out-of-network (OON) provider.  
 
You asked the Plan to pay for the injections. You say that that the claim should be reprocessed. The Plan 
denied your request. The Plan says the injections are available 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a contrast injection for radiological evaluation 
(36598), a heparin injection (J1642), and an alteplase recombinant injection(J2977) provided on December 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 2, 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 (99203) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on May 16, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the dentist should have made you aware 
before she sent you to another dentist that the service would not be covered. You also say that you were 
unaware of your dental benefits and have had 3 oral evaluations already. The Plan denied your request. The 
Plan says your benefit for the limited oral evaluation 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 service was exhausted on date of service May 16, 2023. Therefore, we 
decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) provided on 
May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210) provided on April 24, 2023. 
 
You asked the Plan to pay for the intraoral - complete series of radiographic images. You say that you were 
told that you went over the allowed limit of x-rays and treatments for the year. You also say that you were not 
informed of that and were sent a letter that you would not have any cost. 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 service was exhausted on date of service November 3, 2021. Therefore, we decided 
that the Plan does not have to pay for an intraoral - complete series of radiographic images (D0210) provided 
on April 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items should be covered. 
The Plan denied your request. The Plan says there is no indication the enrollee has lymphedema extending onto 
the chest, trunk and/or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee has 
lymphedema extending onto the chest, trunk and/or abdomen. Therefore, we decided that the Plan does not 
have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical services were called to check on you to see if you were having a stroke. You also say that a 
portable electrocardiogram was processed at your home and the results stated you were just dehydrated. The 
Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 12, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on February 12, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that there was 
no ambulance transport as your injuries were present but not severe enough to transport to hospital. You also 
say that you are submitting the records pertaining to this case. The Plan denied your request. The Plan says 
these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 12, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on February 12, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from February 15, 
2023, to March 11, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee's stay should have been at 
no cost because you were advised the Plan would pay for the extra days. 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 $0 copayment for days 1 to 20 and a $188 copayment for days 21 to 100 for SNF care.  
 
 
  The enrollee has been asked to pay a $752 copayment for a SNF stay ($188 per day x 4 days = $752). This 
item/service falls within the SNF 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 a SNF stay provided from February 15, 2023, to March 11, 2023.