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

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
August 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel you should not be responsible for the 
payment. 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 January 12, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on August 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network office visits provided on 
October 14, 2022. 
 
You asked the Plan to waive the coinsurance for out of network office visits. You say that you shouldnt have 
to pay for this. 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 40% 
coinsurance for Office visits. 
 
You have been asked to pay 40% coinsurance for out of network office visits. This item/service falls within the 
Office visits 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. You have been asked to pay $120 which is 40% of the allowed amount for the out of network office visit. 
Therefore, we decided that the Plan does not have to waive the coinsurance for out of network office visits 
provided on October 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental x-rays provided on September 20, 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 September 15, 2021. 
Therefore, we decided that the Plan does not have to pay for dental x-rays provided on September 20, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on August 
11, 2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that this should be covered. 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 for Ambulance services. 
 
You have been asked to pay a $350 copayment for ambulance transport. This item/service falls within the 
Ambulance 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 copayment for ambulance transport 
provided on August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on June 23, 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 crown has already been 
exhausted, and the coverage for core buildup services is denied as they do not fall under your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service 9/24/2020. Therefore, we 
decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided on 
June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on August 9, 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 February 1, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services provided on August 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a complete upper denture (D5110) and a 
complete lower denture (D5214). 
 
You asked the Plan to waive the coinsurance for the dental services. You say that you are appealing the 
coinsurance that is applied to the dental services. The Plan denied your request. The Plan says the cost sharing 
will be applied according to the Plan contract. 
  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% 
coinsurance for comprehensive dental services including prosthodontics, other oral/maxillofacial surgery, and 
other services. The total allowed amount for the upper denture is $765.25 with a coinsurance amount of 
$306.10 ($765.25 total amount x 40%). The total allowed amount for the lower denture is $845.48 with a 
coinsurance amount of $338.19 ($845.48 total amount x 40% coinsurance). 
 
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 a 40% coinsurance for the dental services. This item/service falls within the dental 
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 a complete upper denture 
(D5110) and a complete lower denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for stress test provided on September 15, 2022. 
 
You asked the Plan to waive the copayment for stress test. You say that you were advised that it would be 
covered at 100%. 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 $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $200 copayment for stress test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 stress test provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on September 22, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that this should be covered. 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 Eye exam. 
 
You have been asked to pay a $40 copayment for eye exam. This item/service falls within the Eye exam 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 eye exam provided on September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a periodic oral evaluation (D0120) 
provided on October 18, 2022. 
 
You asked the Plan to waive the copayment for an evaluation. You say that you did not receive this service. 
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 $25 
copayment for a preventive dental visit.  
 The record shows you received a periodic oral evaluation on October 18, 2022. You have been asked to pay a 
$25 copayment for the evaluation. This item/service falls within the dental 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 copayment for a periodic oral evaluation (D0120) provided on October 18, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170). 
 
You asked the Plan to pre-approve additional mileage for routine transportation. You say that you need to get 
to your medical appointment. The Plan denied your request. The Plan says your benefit only allows 24 one-way 
trips with each one-way trip not exceeding 50 miles of driving distance. 
 
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 the driving distance for a one-way trip is within 50 miles.  
 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. Specifically, the provider is 
located 67 miles away from your residence. The Plan only covers distances up to 50 miles. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foot orthotics. 
 
You asked the Plan to pre-approve a foot orthotics. You say that due to hip replacement surgery, your leg is 
now shorter than the other. Therefore, you need a lift for your shoe, so you do not develop back pain. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental membership provided on November 2, 2022 
 
You asked the Plan to pay for the dental membership. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
membership provided on November 2, 2022
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air and ambulance transport provided on February 25, 2022 
to March 26, 2022. 
 
You asked the Plan to pay for the air and ambulance transport. You say that you would like reimbursement for 
the ambulance services. The Plan denied your request. The Plan says the documentation does not support that 
other means of transport would be contraindicated, such as a stretcher or wheelchair van. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for ambulance services only when they are 
medically reasonable and necessary. The rules also say that Medicare pays for air ambulance services only if 
your medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air and ambulance transport. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found there is no 
documentation from these ambulance transports that have been submitted for review. The air transport is not 
covered as the documentation indicates that you were returning home. While you were non-weight bearing, 
there is no evidence that transport via an air ambulance was medically necessary. Transportation for 
repatriation purposes is not medically necessary as it is only coverable when it occurs to the closest appropriate 
family. You were not transferred to the closest, appropriate facility to receive the emergency services that were 
not available locally. 
 
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 air and ambulance transport have not been met. Therefore, we decided that 
the Plan does not have to pay for air and ambulance transport provided on February 25, 2022 to March 26, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for 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 August 15, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 99232 billed for date of service July 27, 2022. 
 
You asked the Plan to pay for the billed service. You say that the services were rendered by providers in 
different specialties. The Plan denied your request. The Plan says that no modifiers are allowed with code pair. 
99232 and 99239. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99232 is supported. Medicare rules state that claim lines for the same beneficiary, same 
NPI, and same date of service shall be subject to NCCI Procedure-to-Procedure (PTP) edits. The claim shows 
that the code at issue, 99232, and code 99239 were billed on separate dates of service. Based on this 
information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan 
has to pay for procedure code 99232 billed for date of service July 27, 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 pre-approve crowns (D2740 x3). 
 
You asked the Plan to pre-approve crowns. You say that you want the Plan to cover the requested services. The 
Plan denied your request. The Plan says the services at issue are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
crowns (D2740 x3).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Copaxone. 
 
You asked the Plan to pre-approve Copaxone. You say that it is in your medical opinion that this enrollee is 
benefiting from treatment with Copaxone, and they require ongoing treatment with this medication in order to 
avoid deterioration in their health status. The Plan denied your request. The Plan says Copaxone is on the self-
administered drug list and is excluded from coverage under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Copaxone.  
 
  Benefits for Copaxone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 1, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vabysmo. 
 
You asked the Plan to pre-approve Vabysmo. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Vabysmo. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee a diagnosis of diabetic macular edema and a vitreous hemorrhage. The records 
indicate the enrollee has been receiving intraocular injections of bevacizumab and "vision improving with 
injections in both eyes". The Records do not document the rationale for the Vabysmo given the improvement 
with the bevacizumab. The Medicare-approved major drug compendia report no superiority of Vabysmo over 
bevacizumab for treatment of diabetic macular edema and a vitreous hemorrhage. Therefore, the enrollee does 
not meet criteria for the requested drug. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vabysmo have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vabysmo.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Repatha Sureclick injection. 
 
You asked the Plan to pre-approve Repatha. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Repatha 
Sureclick injection.  
 Benefits for Repatha may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.