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

 
We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport 
and ground mileage provided on May 30, 2023. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was transported due to 
hypotensive and blood glucose of 97. The Plan denied your request. The Plan says the enrollee was in an 
inpatient hospital status on this date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that once a beneficiary is admitted to a hospital it 
may be necessary to transport the beneficiary to another hospital or other site temporarily for specialized care 
while the beneficiary maintains inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The Plan must follow Medicare rules. Medicare rules say that 
Medicare rules say that once a beneficiary is admitted to a hospital it may be necessary to transport the 
beneficiary to another hospital or other site temporarily for specialized care while the beneficiary maintains 
inpatient status with the original provider.  
 
We looked at the file and Medicare rules. The records provided demonstrate that the enrollee was receiving 
inpatient hospital care at the time of the transport. This means that the transportation service furnished to the 
enrollee while they were admitted as inpatient would be covered as an inpatient hospital and not paid for 
separately under Part B. Based on this information, we decided that Medicare rules for coverage of the 
ambulance service and ground mileage have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance service, basic life support, emergency transport and ground mileage provided on May 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a comprehensive hearing test (92557) 
provided on June 15, 2023. 
 
You asked the Plan to waive the copayment for a comprehensive hearing test (92557). You say that you went 
for your annual hearing examination. You also say that the service should be covered. The Plan denied your 
request. The Plan says this was a diagnostic hearing examination performed on June 15, 2023. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when it is part of a routine, annual hearing examination.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a comprehensive hearing test (92557) have not been met. Therefore, we decided that the Plan does 
not have to waive the copayment for a comprehensive hearing test (92557) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core build-up (D2950) and an unspecified periodontal 
procedure (D4999) provided on May 8, 2023. 
 
You asked the Plan to pay for D2950 and D4999. You say that this should all be covered under a crown. 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 a core 
build-up (D2950) and an unspecified periodontal procedure (D4999) provided on May 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220/D0230) provided on June 13, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were not told that you would owe this 
amount. 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 June 13, 2023. Therefore, we decided that the Plan does not have to pay for the additional four intraoral images (D0220/D0230) provided 
on June 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita (Q4180 X 160). 
 
You asked the Plan to pre-approve Revita. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 Revita. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that Revita skin graft is not standard of care and does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Revita have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Revita (Q4180 X 160).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. The Plan denied your request. The 
Plan says your benefit for the periodontal scaling and root planing - four or more teeth per quadrant 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 periodontal scaling and root planing - four or more teeth per quadrant was 
exhausted on date of service March 30, 2023. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you have no other way to get to this 
appointment besides using your transportation benefits. The Plan denied your request. The Plan says your 
request is beyond the 50-mile coverage limit.  
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 a maximum of 50 mile trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional mileage for your appointment. Based on this information, we decided that you have exhausted the 
Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional mileage.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 5, 2023. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. 
 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 an $80 
copayment for Emergency Care.  
 
 
  You have been asked to pay an $80 copayment for the ER visit. This item/service falls within the Emergency 
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 an emergency room (ER) visit 
provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral image (D0230) provided on April 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why this is not being 
covered. 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 April 25, 2023. Therefore, we decided that the Plan does not have to pay for an additional intraoral image (D0230) provided on 
April 25, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on April 18, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not be billed for 
these services. 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 $250 
copayment for in and out-of-network one-way emergency and non-emergency ground or air ambulance 
services. 
 
You have been asked to pay a $250 copayment for ambulance services. This item/service falls within the in and out-of-network one-way emergency and non-emergency ground or air 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 services provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composites (D2391/D2392) provided on 
June 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you believe that this should be covered 
fully. 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 resin-based composites (D2391/D2392) 
provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation and intraoral x-ray (D0210 
D0150) provided on July 7, 2023. 
 
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 comprehensive oral evaluation and intraoral x-ray (D0210 D0150) provided on July 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye examination provided on July 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the eye examination. You say that the enrollee was in a nursing home when 
services were rendered and unable to choose a network provider. You say the provider had no prior knowledge 
of which patient they were required to treat. The Plan denied your request. The Plan says there is no prior 
authorization, and the provider was out-of-network. 
 
 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 did not pre-approve the 
eye examination. We found no exception that would require the Plan to pay for the eye examination. Therefore, 
we decided that the Plan does not have to pay for the eye examination provided on July 12, 2023, by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara system-high frequency oscillation lung 
expansion device. 
 
You asked the Plan to pre-approve a Volara system-high frequency oscillation lung expansion device. You say 
that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been 
established. Therefore, coverage criteria have not been met. 
 
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 Volara system-high frequency 
oscillation lung expansion device Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found based on the medical records 
provided there is no documentation that the Volara system-high frequency oscillation lung expansion device at issue in this case meets all Medicare criteria for medically reasonable and necessary and safe and effective for 
the enrollee. 
 
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 Volara system-high frequency oscillation lung expansion device have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system-high frequency 
oscillation lung expansion device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit provided on May 25, 2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit provided 
on May 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardiology visit provided on 
May 10, 2023. 
 
You asked the Plan to waive the copayment for an in-network cardiology visit. You say that this was supposed 
to be a follow up from an AFIB procedure, and should not have a 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 $25 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an in-network cardiology visit. This item/service falls within 
the 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 copayment for an in-network cardiology visit provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lens (V2781) provided on May 4, 2023. 
 You asked the Plan to pay for progressive lens (V2781). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this service is not covered by the Plan. 
 
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 routine eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that you receive a $150 allowance every calendar 
year towards routine eyewear or contact lenses. The record shows that you obtained upgraded lenses, not 
routine. Based on this information, we decided that the Plan's rules for coverage of progressive lens (V2781) 
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens (V2781) 
provided on May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the removal of impacted cerumen (one or 
both ears) by physician on same date of service as audiologic function testing (G0268) provided on May 3, 
2023. 
 
You asked the Plan to waive the deductible for the removal of impacted cerumen (one or both ears) by 
physician on same date of service as audiologic function testing (G0268). You say that you do not believe this 
was performed by the provider. 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. Your 
contract with the Plan says that there is a $650 deductible which applies to physician/practitioner services, 
including in-network doctor's office visits.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $650 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic 
function testing (G0268) was received on May 3, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the removal of impacted cerumen (one or both ears) by physician on same date of 
service as audiologic function testing (G0268) provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on April 26, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you believe these services should be covered. 
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 July 11, 2022, and January 23, 2023. Therefore, we decided that the Plan does not have to pay for periodontal maintenance 
(D4910) provided on April 26, 2023.