Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutment - includes placement 
(D6057) and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve custom fabricated abutment and a crown. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
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 
custom fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown 
(D6058).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on August 29, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says this claim does not meet medical criteria for the ambulance transport. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our 
physician reviewer found the transportation via ambulance from the outpatient appointment was not medically 
necessary.  The enrollee was not bedbound, as evidenced by the ability to sit in a wheelchair. The enrollee did not require 
the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe 
transport.  Transportation could have been provided by other means (stretcher van, wheelchair van, private car, 
taxi) without endangering 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 ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, 
non-emergency transport provided on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit provided on 
November 11, 2022. 
 
You asked the Plan to waive the cost share for a specialist 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 $500 
deductible for physician/practitioner services/specialist.  
 
You have been asked to pay a $500 deductible for a specialist office visit. You are being asked to pay $162 
towards your $500 deductible. This item/service falls within the physician/practitioner services/specialist 
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 a specialist office visit provided 
on November 11, 2022.
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 
August 19, 2021, to August 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told before 
the surgery and hospital stay that it would only be a single $350 copayment. The Plan denied your request. The 
Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment per day for days 1-5 of each inpatient hospital stay. Your contract with the Plan also clearly says you must pay a $0 copayment per day for days 6-90. 
 
You have been asked to pay a $350 copayment per day for days 1-4 of the inpatient hospital stay. These 
items/services fall within the inpatient hospital care category. You have not been charged after day four or for 
the day you were discharged. You have been asked to pay a total of $1,400 ($350 copayment per day x 4 days 
= $1,400). 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 
August 19, 2021, to August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (POV) (K0800). 
 
You asked the Plan to pre-approve a motorized scooter. You say that you need the scooter to get around better 
with the ramp that you have at home. The Plan denied your request. The Plan says a group 1 powered 
wheelchair is insufficient to meet your needs. The documentation does not provide any new information to 
warrant a group-1 powered wheelchair versus the recommended group-3 powered wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 The file shows that the requested scooter is not medically necessary for your condition. The notes do not show 
that you will be using this device in the house. The records show that you had a wheelchair evaluation 
completed on March 10, 2023, and the request for the requested group 1 wheelchair was denied. The records 
also show that the Plan has approved a group 3 powered wheelchair with special features as you are 
independent with transfers and weigh shifting. This means that Medicare rules for coverage of a motorized 
scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 1 power 
operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 94761 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the code is bundled into payment for other services. 
 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 94761 is not separately payable as it is billed on the same date by the same provider as 
other payable services. 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 94761 
billed for date of service April 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3/4 crowns on teeth #26 and #27. 
 
You asked the Plan to pre-approve 3/4 crowns. You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 3/4 
crowns on teeth #26 and #27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain fused to high noble meta (D2750) x3 
and core buildup, including any pins when required (D2950). 
 
You asked the Plan to pre-approve dental services. You say that you cannot afford the charges for the services 
received. The Plan denied your request. The Plan says these services are not covered under your 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. Crown - porcelain fused to 
high noble meta (D2750) and core buildup, including any pins when required (D2950) are not covered under 
the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D2750 and D2950 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crown - porcelain fused to high noble meta (D2750) x3 and core buildup, including any pins when required 
(D2950).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the colorectal cancer screening (G0328) provided on 
December 21, 2022. 
 
You asked the Plan to hold you harmless for the colorectal cancer screening. You say that you had been sick, 
and your provider requested additional lab work, including this test. The Plan denied your request. The Plan 
says that this test is covered only once every 12 months, and your claims history shows that you previously 
received this test on December 8, 2022. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the colorectal cancer screening by a contract provider. The file does not show that the 
Plan provided notice that the colorectal cancer screening would not be covered. In addition, the file indicates 
that medical records were requested from the contracted provider, but no records were received. It is not clear if 
this testing was actually provided as a screening or was a diagnostic exam performed to investigate your 
symptoms, complaints, or findings from the previous screening. If this were the case, this service may not have 
been coded correctly, which is not your responsibility. Under Medicare rules, this means the colorectal cancer 
screening is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for 
the colorectal cancer screening (G0328) provided on December 21, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service December 2, 
2022. 
 You asked the Plan to pay for procedure code 86077. You say that the service provided was medically 
necessary. 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 cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service December 2, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
  You asked the Plan to pre-approve additional mileage. You say that you need to see the pain management 
doctor once every two months because your leg was amputated due to a motorcycle accident. You also say that 
you need to see the pain management doctor for medication that you need for your leg. The Plan denied your 
request. The Plan says you are requesting 27.7 additional miles for routine transportation. The Plan also says 
that your benefit only allows 50 miles for one-way trips. 
 
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 routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular orthopedic repositioning device (S8262) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a mandibular orthopedic repositioning device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not a participating provider, and services can be 
rendered at an in-network provider. 
 
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 mandibular orthopedic repositioning device (S8262) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that you need this item. The Plan 
denied your request. The Plan says total electric hospital bed is not a covered benefit as the height adjustment 
feature is a convenience feature. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the fundus photography. We decided that the Plan does not have to pay 
for the miscellaneous vision services, the lenses and the frames.  
 
You asked the Plan to pay for the fundus photography, the miscellaneous vision item, the single lens (x2), and 
the frames (x2) provided on December 1, 2022. You say that you were told you would be refunded the entire 
out-of-pocket amount. The Plan says that fundus photography and miscellaneous vision item is not a covered 
benefit. The Plan says that the benefit for the lenses and the frames has been exhausted. 
 
We decided that the Plan has to pay for the fundus photography.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find it is not appropriate to consider coverage of the fundus photography 
under the Plan's supplement benefit, as it is an active code that can be covered by Medicare. The Plan did not 
show a valid denial based on Medicare rules. Therefore, we decided that the Plan has to pay for the fundus 
photography.  
 
We also decided that the Plan does not have to pay for the miscellaneous vision item, the lenses, and the 
frames. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover the miscellaneous vision item and covers one set of lenses and one pair of 
frames once a year. 
 
We looked at the file and the Plan's rules. Specifically, the miscellaneous vision item is not a covered benefit. 
Also, you received a one set a lens, and one pair of frames on December 1, 2022, which exhausted the benefit. 
Based on this information, we decided that the Plan's rules for coverage of the miscellaneous vision item, the 
lenses, and the frames have not been met. Therefore, we decided that the Plan does not have to pay for the 
miscellaneous vision item, the lenses, and the frames. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient rehabilitation facility (IRF) care provided from 
September 1, 2021, through September 16, 2021. 
 
You asked the Plan to pay for IRF care. You say that that the plan should make an exception to the timely filing 
denial. The Plan denied your request. The Plan says the claim was not received in a timely manner. 
 
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 IRF care was not filed until November 23, 2022. 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 inpatient rehabilitation facility (IRF) care provided from September 1, 2021, 
through September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6740) for tooth #10, #11 and #12. 
 
You asked the Plan to pre-approve the dental services. You say that you need the services since it has been 
difficult to eat. 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 Plan's 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 April 12, 2023 when the Plan authorized 
one pontic for tooth #9 and three retainer crowns for tooth #6, #7 and #8. Therefore, we decided that the Plan does 
not have to pre-approve retainer crowns (D6740) for tooth #10, #11 and #12.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the MRI scans provided from October 19, 
2022, to October 25, 2022. 
 
You asked the Plan to reduce the copayments for the MRI scans. You say that you had to get two MRIs and 
were told you may be able to get the copayment for the first one waived. 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 $150 
copayment for diagnostic radiology services, including MRIs. 

You have been asked to pay a $150 copayment for each MRI scan. These items/services fall within the 
outpatient diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of 
$300 ($150 copayment + $150 copayment = $300). 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 copayments for 
MRI scans provided from October 19, 2022, to October 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 24, 
2022. 
 
You asked the Plan to pay for procedure code 93042. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code 
93010. 
 
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 93042 
is a column II code to column I code 93010. 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. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service August 24, 2022.