Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from July 5, 
2019, to July 19, 2019. 
 
You asked the Plan to pay for SNF services. You say that you were not informed about the time frame allowed 
for the appeal and kindly ask for the timely filing to be waved. The Plan denied your request. The Plan says 
claim is denied due to untimely filing. 
 
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 SNF services was not filed until June 28, 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 skilled nursing facility (SNF) services provided from July 5, 2019, to July 19, 
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown, unspecified preventive procedure, and sales tax 
(D2740, D1999, D9958) provided on October 31, 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 and could not wait another year for the crown to be covered. The Plan denied your request. The 
Plan says your benefit for the crown (D2740) had already been exhausted, coverage for the unspecified 
preventive procedure and sales tax denied correctly as they do not fall within your dental benefits (D1999, 
D9958). 
 
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 June 28, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown, unspecified preventive procedure, and sales tax 
(D2740, D1999, D9958) provided on October 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the mechanical traction therapy 
(97012) provided from October 18, 2022, through November 17, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. 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 the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99204) and the mechanical traction therapy (97012) 
provided from October 18, 2022, through November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that these services are medically necessary. The Plan 
denied your request. The Plan says there is no authorization on file for the services provided. 
 
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 an office visit provided on August 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and periodontal maintenance 
(D0120, D4910) provided on August 31, 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 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 requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation and periodontal maintenance (D0120, D4910) provided on August 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation and periodontal maintenance 
(D4910, D0140) provided on August 2, 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 the services denied correctly as they do not fall 
within your dental benefits. Limited oral evaluations are only covered when performed by an oral surgeon. 
 
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 limited 
oral evaluation and periodontal maintenance (D4910, D0140) provided on August 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 21, 2022, to 
April 18, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that the NOA was submitted. 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 looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
was not billed with the first period of care 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 March 21, 2022, to April 18, 2022.
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 16, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your port 
was bleeding and you could not control it. You also say that you were always told to call 911 to be treated and 
not transported. 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 16, 2022. 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 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation and intraoral x-ray 
(D0150, D0210) provided on June 15, 2022, to June 20, 2022. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation and 
intraoral x-ray (D0150, D0210) provided on June 15, 2022, to June 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277 x56). 
 
You asked the Plan to pre-approve HBO therapy. The Plan denied your request. The Plan says your diagnoses 
are not included in the covered conditions for hyperbaric oxygen therapy. The Plan also says this service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that no program payment may be made for 
hyperbaric oxygen (HBO) in the treatment of Cutaneous, decubitus, and stasis ulcers or Chronic peripheral 
vascular insufficiency. 
 
We looked at the file and Medicare rules. The records show that you are requesting these services for the 
diagnoses of Venous insufficiency (chronic) (peripheral) and Chronic venous hypertension with ulceration 
right lower extremity. Based on this information, we decided that Medicare rules for coverage of HBO therapy 
have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) 
therapy (G0277 x56).
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 July 14, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the enrollee was transported home after being treated at a facility for back pain. You also say that the enrollee 
has severe weakness and is unable to stand. The Plan denied your request. The Plan says the ambulance 
transport was not medically necessary. 
 
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 service was not medically necessary.  Our physician reviewer found the transportation via ambulance from the emergency department to the 
enrollee's residence was not medically necessary. 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 July 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer 
procedure (22869). 
 
You asked the Plan to pre-approve a posterior interspinous decompression spacer procedure. You say that this 
service is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental. 
 
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 a posterior interspinous decompression 
spacer procedure. Our reviewer says that the requested service is not considered medically reasonable and 
necessary in this case. Our physician reviewer found current evidence based medical guideline and peer 
reviewed literature do not fully support the spinal decompression device procedure over the gold standard of 
lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the 
use of this device for this enrollees medical condition and there is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a posterior interspinous decompression spacer procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression 
spacer procedure (22869).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you would 
like to appeal this service. The Plan denied your request. The Plan says this claim processed correctly, as 
Medicare does not cover treatment with no transport. 
 
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 5, 2022. The record shows that you 
signed a refusal to be transported by the ambulance, acknowledging you would accept full responsibility. 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 (A0998) provided on February 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous peripheral arterial angioplasty with stent 
placement (37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37221, and 37220). 
 
You asked the Plan to pre-approve percutaneous peripheral arterial angioplasty with stent placement. You say 
that the services are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 percutaneous peripheral arterial 
angioplasty with stent placement. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the enrollee has evidence of lower extremity pain but no evidence of significant 
peripheral arterial disease as the cause of her symptoms, including ankle brachial index (ABI) assessments and 
non-invasive imaging. As such, guidelines for PTA are not met. In summary, there is insufficient 
documentation to support the medical necessity for PTA in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous peripheral arterial angioplasty with stent placement have not been 
met. Therefore, we decided that the Plan does not have to pre-approve percutaneous peripheral arterial 
angioplasty with stent placement (37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37221, and 
37220).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on September 26, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with the 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 $225 
copayment for outpatient diagnostic tests/CT.  
 
You have been asked to pay a $225 copayment for CT scan. However, you are only being asked to pay $93 
which is less than the required amount. This item/service falls within the outpatient diagnostic tests/CT 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 computed tomography (CT) scan provided on 
September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says there is no authorization on file for the services rendered. 
 
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 an office visit provided on August 2, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rotary wing air transport (A0431) and rotary wing air 
mileage (A0436) provided on December 4, 2021. 
 
You asked the Plan to pay for the rotary wing air transport and mileage. You say that the enrollee's family 
decided on December 4, 2021, that the enrollee had to get out of the foreign hospital, and back to the United 
States for proper care or they were going to die. You also say that the enrollee was able to use their insurance 
cards and information for services upon their return to the United States, and you are requesting reimbursement 
for the services. The Plan denied your request. The Plan says these services are denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for the services listed in the Medicare rules section of this letter, and 
certain services rendered on board a ship  
 
We looked at the file and Medicare rules. Specifically, the record shows that the enrollee was transported from 
outside of the country back to the United States for treatment due to COVID-19. The 2021 Evidence of 
Coverage clearly states that transportation back to the United States from another country is not covered. Based 
on this information, we decided that Medicare rules for coverage of the rotary wing air transport and mileage 
have not been met. Therefore, we decided that the Plan does not have to pay for the rotary wing air transport 
(A0431) and rotary wing air mileage (A0436) provided on December 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on August 24, 2022. 
 
You asked the Plan to pay for the refraction. You say that you had a diabetic eye exam and refraction which are 
covered benefits. The Plan denied your request. The Plan says the refraction is not a covered benefit. 
 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 covers these services when completed during a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, refractions are covered during routine eye exams. Based 
on this information, we decided that the Plan's rules for coverage of the refraction have not been met. 
Therefore, we decided that the Plan does not have to pay for the refraction provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided on September 28, 2022, to 
October 19, 2022. 
 
You asked the Plan to pay for chiropractic care. You say that you are requesting reconsideration. 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 chiropractic care 
provided on September 28, 2022, to October 19, 2022.