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

 
We decided that the Plan does not have to pre-approve non-emergent routine transportation (A0100, S0215), to 
an out-of-network (OON) providers office. 
 
You asked the Plan to pre-approve non-emergent routine transportation. You say that you have suffered from 
back pain for over 18 years. Prior to being treated by this provider, you have sought treatment from several 
specialists which did not help, and this provider's treatment has greatly helped to alleviate your pain. The Plan 
denied your request. The Plan says the transportation requested is for transportation service to a provider that is 
not in the network and prior authorization is required. 
 
 
 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 unlimited trips to a plan-approved location.  
 
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. The EOC confirms the Plan 
covers unlimited trips to a plan-approved location. The requested provider is OON; therefore, transportation is 
not approved to this location. Therefore, we decided that the Plan does not have to pre-approve non-emergent 
routine transportation (A0100, S0215), to an out-of-network (OON) providers office.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services billed in addition to the inpatient services 
provided from June 9, 2021, to July 2, 2021. 
 
You asked the Plan to pay for the services billed in addition to the inpatient services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 
separately payable. 
 
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 the additional services billed in addition to the inpatient services are not supported in the medical 
record. Specifically, the services that were billed in addition to the inpatient services are considered unbundled 
and are therefore, not separately payable. In addition, the services for continuous positive airway pressure and 
bi-level positive airway pressure are denied as they are a duplicate charge as they were billed twice for the date 
of service June 29, 2021. Based on this information, we decided that Medicare rules for coverage of the 
services billed in addition to the inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pay for the services billed in addition to the inpatient services provided from June 9, 2021, to July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite filling on tooth #6 (D2335) 
and resin based composite fillings on tooth #7 (D2330, D2332) provided on March 15, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you cannot afford this bill. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing 
amount when your services are received from an out-of-network provider. The Plan also says that your benefit 
for fillings has 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. 
 
The record shows the Plan paid for two fillings during the processing of this claim; therefore, the benefit for 
fillings have been exhausted. You have been asked to pay the difference between the out-of-network provider's 
charges and the Plan's 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 resin-based 
composite filling on tooth #6 (D2335) and resin based composite fillings on tooth #7 (D2330, D2332) 
provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network annual wellness visit on 
April 25, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network annual wellness visit. You say that you 
would like to appeal the cost share. The Plan denied your request. The Plan says when seen by an out-of-
network provider for an annual routine physical exam, the member pays 30% of the total allowed amount for 
one routine physical exam each calendar year. 
 
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 30% 
coinsurance for an out-of-network annual wellness visit. The total allowed amount of the out-of-network 
annual wellness visit is $136.16, resulting in a coinsurance amount of $40.85. 
 
You have been asked to pay 30% coinsurance for an out-of-network annual wellness visit. An out-of-network 
annual wellness visit falls within the annual wellness visit 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 an out-of-network annual wellness visit on April 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found IRF admission is not medically necessary based lack of medical complexity and 
acute rehabilitation nursing needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6241) for tooth #'s 18 and 19, and retainer 
crowns (D6751) for tooth #'s 17 and 20. 
 
You asked the Plan to pre-approve pontics and retainer crowns. The Plan denied your request. The Plan says 
these services do not meet the criteria for coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers pontics and 
retainer crowns when the services are medically necessary and reasonable.  
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve pontics and retainer crowns. Our 
reviewer says that the criteria for coverage for a posterior fixed bridge replacing missing teeth #'s 18 and 19 
have not been met. Our physician reviewer found coverage for fixed bridges are limited to the replacement of a 
single maxillary anterior tooth or two adjacent mandibular anterior teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontics and retainer crowns have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pontics (D6241) for tooth #'s 18 and 19, and retainer crowns (D6751) for 
tooth #'s 17 and 20.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for localized delivery of antimicrobial agents (D4381), 
adjunctive pre-diagnostic tests (D0431), and drugs medicaments dispensed in the office (D9630), provided by a 
participating provider on January 25, 2022. 
 
You asked the Plan to pay for localized delivery of antimicrobial agents, adjunctive pre-diagnostic tests, and 
drugs medicaments dispensed in the office. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the denied services are not covered 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, 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 localized delivery of antimicrobial agents (D4381), adjunctive pre-diagnostic tests (D0431), and drugs medicaments 
dispensed in the office (D9630), provided by a participating provider on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and surgical 
implant index (D6190) provided on March 22, 2022, and endosteal implants (D6010 x 6) and moderate 
sedation (D9243) provided on March 31, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services were covered. The 
Plan denied your request. The Plan says endosteal implants (D6010), moderate sedation (D9243), and surgical 
implant index (D6190) are not covered by your supplemental dental benefits. The Plan also says a 
comprehensive oral evaluation (D0150) is covered once every three years; however, your benefit for this 
service has 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, endosteal implants (D6010), moderate 
sedation (D9243), and surgical implant index (D6190) are not among those covered under this benefit. The 
record shows the Plan paid for a comprehensive oral evaluation (D0150) provided on October 6, 2021; 
therefore, the benefit for one comprehensive oral evaluation has been exhausted. We decided that the Plan does 
not have to pay for a comprehensive oral evaluation (D0150) and surgical implant index (D6190) provided on 
March 22, 2022, and endosteal implants (D6010 x 6) and moderate sedation (D9243) provided on March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system 
(L5981). 
 
You asked the Plan to pre-approve an all-lower extremity prosthesis. You say that the requested prostheses is 
medically necessary. The Plan denied your request. The Plan says the request for K3 prosthesis exceeds the 
enrollee's need and does not meet Medicare criteria as reasonable and necessary. 
 
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 an all-lower extremity prosthesis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found clinical documentation shows that the enrollee is not currently at a K3 
functional level and requires assistance with transfers without commenting on potential K3 level activities thus 
a K3 level foot is not medically reasonable. Clinical documentation also states that the enrollee would benefit 
from increased stability which would not be better suited by a K3 level foot as a K3 level foot provides 
increased flexibility to allow for different cadences over multiple environments. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an all-lower extremity prostheses have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system (L5981).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiac diagnostic test provided on February 11, 2022. 
 
You asked the Plan to pay for the cardiac diagnostic test. You say that the services should be paid as Plan 
directed care. The Plan denied your request. The Plan says 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 Plan says 
that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 and the referring provider in this case are not network providers with the Plan. The Plan 
did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for a cardiac diagnostic test provided on 
February 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided on October 
5, 2021, by the advanced life support (ALS) provider. 
 
You asked the Plan to pay for the ambulance service. You say that you thought you were having a heart attack. 
You say that you received a bill for $1,200. You also say that the transport was medically necessary and should 
be covered. The Plan denied your request. The Plan says the claim processed correctly. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the 
services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that ALS ambulance provider does not have a contract with the volunteer ambulance 
company that provided the transport services. Additionally, the record shows that the ambulance transport was 
paid. Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service (A0999) 
provided on October 5, 2021, by the advanced life support (ALS) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) provided by a participating provider. 
 
You asked the Plan to pre-approve a crown. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the medical criteria for D2751 has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown. Our reviewer says that a 
crown is not medically necessary. Our physician reviewer found the documentation provided shows that the 
criteria for a crown restoration for tooth #10 has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2751) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment - includes modification and 
placement (D6056) and surgical placement of implant body: endosteal implant (D6010) on January 10, 2022. 
 
You asked the Plan to pay for a prefabricated abutment - includes modification and placement and surgical 
placement of implant body: endosteal implant. You say that you would like to appeal the denial of the claim. 
The Plan denied your request. The Plan says this procedure is not covered under your dental plan. 
 
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, 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 
prefabricated abutment - includes modification and placement (D6056) and surgical placement of implant 
body: endosteal implant (D6010) on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services (99305) provided on November 23, 
2021. 
 
You asked the Plan to pay for skilled nursing services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that for all services (with two (2) exceptions), the 
Place of Service (POS) code to be used by the physician or other supplier will be assigned as the same setting 
in which the beneficiary received the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of skilled nursing services have not been met. Specifically, this claim was billed with the POS code 
for a skilled nursing facility setting. The case record does not support that the enrollee was a patient in a skilled 
nursing facility at the time services were rendered. Therefore, we decided that the Plan does not have to pay for 
skilled nursing services (99305) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $19.40 coinsurance for an oxygen concentrator provided 
on October 28, 2021. 
 
You asked the Plan to waive the $19.40 coinsurance for an oxygen concentrator. You say that you should not 
be responsible for the coinsurance because you returned the oxygen concentrator the next day. The Plan denied 
your request. The Plan says the coinsurance has been correctly applied. 
 
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% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies received from an out-of-network 
supplier.  
 
 
 
 
 You have been asked to pay a $19.40 coinsurance for an oxygen concentrator. An oxygen concentrator falls 
within the Durable Medical Equipment (DME) and Related 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. Your contract with the Plan clearly 
says that you must pay a 25% coinsurance for Durable Medical Equipment received from out-of-network 
suppliers. However, you have only been asked to pay $19.40, which is less than the 25% coinsurance. 
Therefore, we decided that the Plan does not have to waive the $19.40 coinsurance for an oxygen concentrator 
provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating provider 
January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told this would be covered because it 
was a new year. 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 December 3, 2021. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided by a participating 
provider on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fillings (D2391, D2331 x 2) provided on July 27, 2021, 
by the out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you had a cavity. You say that you did not want 
it to turn into an abscess and need a root canal. You also say that you were not able to find an in network 
provider within 50 miles that could see you. The Plan denied your request. The Plan says dental services 
received out of network are not covered. 
 
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, the fillings are not among those 
covered under this benefit when performed by an out of network provider. Therefore, we decided that the Plan 
does not have to pay for the fillings (D2391, D2331 x 2) provided on July 27, 2021, by the out of network provider.