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

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) and 
ground mileage (A0425) provided on April 7, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation and ground mileage. You say that 
this claim was originally filed with another provider, and you did not get their denial until July 20, 2022. You 
also say that once you got that denial, you filed with the enrollee's insurance plan, which was also denied. The 
Plan denied your request. The Plan says this claim was received on August 10, 2022, which is past the allowed 
12-month timeframe. 
 
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 the non-emergency ambulance transportation and ground mileage was not 
filed until August 10, 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 the non-emergency 
ambulance transportation (A0428) and ground mileage (A0425) provided on April 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a specialist office visit and injection 
provided on July 12, 2022. 
 
You asked the Plan to waive the cost share for a specialist office visit and injection. You say that you didn't 
know the cost would be so high. 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 20% 
coinsurance for each Medicare-covered Part B drug and $10 copayment for each specialty physician visit.  
 
 You have been asked to pay $2,113.60 which is 20% of the allowed amount for the Medicare Part B drugs. The 
allowed amount is $10,568(20% x $10,568= $2,113.60). You have also been asked to pay $10 copayment for a 
specialist office visit. This item/service falls within the Medicare Part B prescription drugs and 
Physician/Practitioner services, including doctors 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. Therefore, we decided that the Plan does not have 
to waive the cost share for a specialist office visit and injection provided on July 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on 
February 14, 2022, to February 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the 
charge. 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 $285 
copayment for each day for days 1 to 6 for inpatient hospital care. This inpatient hospital stay lasted 4 days, 
resulting in a copayment amount of $1,140.00 ($285 per day for 4 days = $1,140.00). 
 
You have been asked to pay $285 copayment for each day for days 1 to 6 for inpatient hospital care. This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital care provided on February 14, 2022, to February 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that you rely on the facility to obtain pre-
certification or authorization. You also say the service was medically necessary and you are appealing with 
supporting records. The Plan denied your request. The Plan says the enrollee must receive care from a 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 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 nursing facility care provided on March 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crutch substitute, lower leg platform provided on June 25, 
2022, by an OON provider. 
 
You asked the Plan to pay for the crutch substitute, lower leg platform. The Plan denied your request. The Plan 
says the out-of-network services were not authorized and the Plan has in-network durable medical equipment 
providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a crutch substitute, lower leg platform provided on 
June 25, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pressure reducing support surface billed with code 
E1399. 
 
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says this is not 
the correct code. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
 The file shows that a pressure reducing mattress was requested with code E1399. The file shows that the Plan 
has agreed to pre-approve a pressure reducing mattress with a code suitable for payment. The requested item, 
billed with an incorrect code, serves the same purpose as the approved item. Therefore, we decided that the 
Plan does not have to pre-approve a pressure reducing support surface billed with code E1399.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) and core buildup (D2950) for tooth 
#30. 
 
You asked the Plan to pre-approve the dental services. You say that you are experiencing pain when you chew, 
and you need to have the dental procedures done. The Plan denied your request. The Plan says your benefit for 
the crown has already been exhausted. The Plan denied the core buildup because the x-rays show the tooth has 
too little bone in the middle of the roots. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the crown and core buildup for tooth #30 is not medically necessary. Our physician reviewer found that 
there is noted periodontal disease as evidenced by the furcation involvement with loss of bone. The long-term 
prognosis of a tooth with a periodontal condition involving the furcation area of a molar is poorer than if the 
attachment was maintained over the level of the furcation. The tooth must be shown to have a long history of 
periodontal stability over time with a regular periodontal maintenance before it could be considered for a crown 
restoration due to the propensity of such teeth to rapidly fail. 
 
The Plan does not allow for crowns to be placed unless the enrollee must be free from active and advanced 
periodontal disease. In order to have a furcation involvement, there must be some advanced level of attachment 
loss from periodontal disease. The long-term prognosis is poorer for a molar tooth with bone loss in the 
furcation area.  Given the specified limitations of the policy the criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. The record shows your benefit for the crown 
was exhausted on the date of service of April 10, 2019. Based on this information, we decided that the Plan's 
rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) and core buildup (D2950) for tooth #30.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs provided on January 11, 2022. 
 
You asked the Plan to pay for the services provided. You say that medical records were provided for review. 
The Plan denied your request. The Plan says the billed codes and units cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, CPT code J3490 was billed for drug Bupivacaine Hydrochloride. The claim shows that 2 units of 
service was billed. We find that 2 units of CPT code J3490 is not supported in the medical record. Based on 
this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the drugs provided on January 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that in December of 2021, you were approved 
for your lower partial dentures, but you never went back to finish your partials because you became extremely 
ill. 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 18, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214).  
 Your complaint about potentially not receiving your partial dentures is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for bitewing x-rays (D0274) provided on July 19, 2022. 
 
You asked the Plan to pay for the bitewing x-rays. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for bitewing x-rays (D0274) provided on July 19, 
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 pay for the risk assessment and documentation (D0603), the pre-
diagnostic test (D0431), the bone replacement graft (D7953), and the office visit (D9440) for tooth #30 
provided on June 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were in pain and the dentist said the service 
would be covered. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the risk assessment and documentation, the pre-diagnostic test, the bone replacement graft, and 
the office visit are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the risk 
assessment and documentation (D0603), the pre-diagnostic test (D0431), the bone replacement graft (D7953), 
and the office visit (D9440) for tooth #30 provided on June 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the extraction 
(D7140), and the first periapical x-ray (D0220) provided on June 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that it is not possible to have an insurance 
"dental plan" which does not cover pulling out bad teeth. 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. Also, 
the extraction is not a covered benefit. Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation (D0140), the 
extraction (D7140), and the first periapical x-ray (D0220) provided on June 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the dental 
services on July 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for biopsy, breast, with placement of breast
localization device(s) provided on May 28, 2021.
You asked the Plan to waive the copayment for biopsy, breast, with placement of breast localization device(s).
You say that you are disputing the share cost. 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 $500
copayment for outpatient hospital services.
You have been asked to pay $500 copayment for biopsy, breast, with placement of breast localization
device(s). This item/service falls within the outpatient hospital 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 biopsy, breast, with placement of breast localization device(s)
provided on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heavy duty, extra wide hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 
(E0303) gel pressure mattress pad (E0185) 
 
You asked the Plan to pre-approve the hospital bed and gel mattress. You say that you cannot turn on a regular 
bed because of your size so you need an extra wide bed to be able to turn and change positions. You need the 
gel mattress so you can sleep more comfortably. You would like to be able to sleep comfortably. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for a heavy-duty hospital 
bed or gel mattress. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file, and Medicare rules. The records show that the enrollee weighs 305 pounds. The criteria 
for the requested bed is 350 to 600 pounds. The gel mattress is being requested for comfort and the enrollee 
does not meet the Medicare criteria. Based on this information, we decided that Medicare rules for coverage of 
the hospital bed and gel mattress have not been met. Therefore, we decided that the Plan does not have to pre-
approve heavy duty, extra wide hospital bed, with weight capacity greater than 350 pounds, but less than or 
equal to 600 pounds, with any type side rails, with mattress (E0303) gel pressure mattress pad (E0185)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 the dental services on May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the surgery will be done on 
December 6, 2022, to treat lumbar spondylolisthesis, foraminal stenosis, lumbar radiculopathy, degenerative disc disease and lumbar pain. You also say that the patient is in severe pain with weakness and having 
difficulty ambulating. The Plan denied your request. The Plan says the actual level of care required for this 
service may or may not warrant an inpatient stay. The Plan also says that after the surgery, if the physician 
believes an inpatient level of care is warranted, please notify the Plan of the admission at that time. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Our physician reviewer also found that 
the record does not show that at the time of inpatient admission, the admitting physician would reasonably 
expect that the patient's necessary hospital care would span two midnights. Our physician reviewer also found 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental extraction (D7210) provided on June 30, 2022. 
 
You asked the Plan to pay for the dental extraction. 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. 
 
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 dental 
extraction (D7210) provided on June 30, 2022.